Fork Mountain Adult Rest Home

Based on staff record review, the facility failed to ensure that training and orientation for new employees occurred within the first seven working days of employment. EVIDENCE: 1. The record for staff person 2, hired on 11/03/2025, has a record of initial ALF staff training form that is blank. The employee schedule has documentation that this employee has worked over seven days since their date of employment.

Based on observations and staff interviews, the facility failed to notify the regional licensing office in writing within 14 days of a change in the facility administrator, including the appointment of an acting administrator. EVIDENCE: 1. During an interview conducted by 2 licensing inspectors (LIs) on 11/19/2025 with staff persons 1 and 5, staff person 5 acknowledged that they resigned from their position as the facility administrator effective 10/31/2025. Staff person 1 expressed that they were currently in an administrator in training program and had become the facility acting administrator effective 11/01/2025. As of the date of on-site inspection the facility has not provided in writing notification of the change in facility administrator to include the appointment of staff person 1 as the acting administrator.

Based on staff record review, the facility failed to ensure that direct care staff receive at least 18 hours of training annually. EVIDENCE: 1. The record for staff person 3, hired on 10/4/2024, does not contain documentation that the employee has completed any of the 18 hours of required annual training from 10/04/2024 through 10/04/2025.

Based on staff record review and staff interviews, the facility failed to ensure that a record was established for each staff person. EVIDENCE: 1. The employee schedule for October and November 2025 has staff person 4 listed on the schedule. In an interview with staff persons 1 and 5 on the day of on-site inspection, it was explained that a record for staff person 4 was not available in the facility for review.

Based on staff record review, the facility failed to ensure that all required personal and social data maintained on staff was included in the staff record. EVIDENCE: 1. In an interview with 2 licensing inspectors (LIs) and staff person 1 on the day of on-site inspection, staff person 1 explained that she became the acting administrator of the facility effective 11/01/2025. The record for staff person 1 does not contain verification that they have received a job description for their current position as the acting administrator. 2. The record for staff person 3, hired on 10/04/2024, has a job description signed by staff person 3 on 10/04/2024 that includes duties for Direct Care/Nursing Assistant/Med. Tech. In an interview with 2 LI?s and staff persons 1 and 5, it was explained that staff person 3 is a direct care aide only and is not registered as a medication aide and that the Med. Tech duties should not be included in staff person 3?s job description.

Based on staff record review, the facility failed to ensure that all employees submitted the results of a risk assessment, documenting the absence of tuberculosis in a communicable form on or within seven days prior to the first day of work at the facility. EVIDENCE: 1. The record for staff person 2, hired on 11/03/2025, contained a Virginia Department of Health Report of Tuberculosis Screening form with a date of 10/23/2025 that is blank and contains no information on the tuberculosis screening. 2. The record for staff person 3, hired on 10/04/2025, did not contain documentation of a screening for tuberculosis in the staff persons record.

Based on staff record review, the facility failed to ensure that all direct care staff members maintained certification in first aid and that at least 1 staff person with current certification in first aid was in the building at all times. EVIDENCE: 1. The records for staff persons 1 and 5 have documentation that their certification in first aid expired in August 2025. A roster from a local public safety training center was provided to the licensing inspector on the day of on-site inspection but the roster has documentation that on 11/04/2025, staff persons 1 and 5 only took courses for BLS (basic life support) and not first aid. 2. The records for staff persons 1 and 5 have documentation that their certification in first aid expired in August 2025. The employee schedule for October 2025 has documentation that staff persons 1 and 5 were the only direct care employees working on the 1st shift on 10/07/2025. In an interview with staff persons 1 and 5 on the day of on-site inspection, staff persons 1 and 5 explained that this was accurate.

Based on staff record review, facility employee schedule review and staff interviews, the facility failed to ensure that at least 1 staff person with current certification in cardiopulmonary resuscitation (CPR) was in the building at all times. EVIDENCE: 1. The records for staff persons 1 and 5 have documentation that their certification in CPR expired in August 2025. The employee schedule for October 2025 has documentation that staff persons 1 and 5 were the only direct care employees working on the 1st shift on 10/07/2025. In an interview with staff persons 1 and 5 on the day of on-site inspection, staff persons 1 and 5 explained that this was accurate.

Based on review of the facility employee schedule, the facility failed to ensure that all required information was included on the written work schedule. EVIDENCE: 1. The facility written work schedules from 10/06/2025 through 11/30/2025 do not include the job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.

Based on resident record review and staff interviews, the facility failed to ensure that a fall risk rating was completed after a fall for resident residents who meet the criteria for assisted living care. EVIDENCE: 1. The record for resident 1 has documentation of a self-reported incident dated 11/06/2025 in which resident 1 fell and was sent to the local emergency room for evaluation. The record for resident 1, who is assessed as assisted living level of care on a uniform assessment instrument ( UAI

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

Based on resident record review, the facility failed to ensure that when hospice care is provided to a resident, the services provided by hospice were included on the residents individualized service plan ( ISP

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

Based on resident and staff record review, the facility failed to ensure that resident rights and responsibilities were reviewed annually. EVIDENCE: 1. The record for resident 1, admitted on 07/23/2023, and resident 2, admitted on 05/02/2007, did not contain documentation that these residents have been provided an annual review of resident rights and responsibilities. 2. The record for staff person 3, hired on 10/04/2025 does not have documentation that the employee has had an annual review of resident rights and responsibilities since their date of hire.

Based on resident record review, observations of the facility medication cart and staff interviews, the facility failed to implement their medication management plan (MMP) in regard to methods to prevent the use of outdated, damaged, or contaminated medications and EVIDENCE: 1. The facility MMP has documentation that the use of an outside pharmacy helps to reduce the use of outdated, damaged or contaminated medication. At approximately 12:18pm on the day of on-site inspection 2 licensing inspectors in the presence of staff person 1 observed a Insulin Lispro pen that was open and in use for resident 3. The pen was not labeled with an open or discard date to ensure that the pen is discarded within 28 days of opening per manufacturer?s instructions. In an interview with staff persons 1 and 6 it was explained that all insulin pens are to be labeled at the time they are opened so staff know when to discard them. 2. The facility MMP has documentation that they have two staff LPN?s that verify the medication orders have been accurately transcribed to the medication administration record ( MAR

Based on observations of the facility medication cart, the facility failed to ensure that Schedule II drugs and any other drugs subject to abuse must be kept in a separate locked storage compartment (e.g., a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart). EVIDENCE: 1. During an audit of the facility medication cart on the day of on-site inspection, 2 licensing inspectors (LIs) in the presence of staff person 1, observed that the scheduled medication Gabapentin 100mg for resident 7 was in the 3rd drawer of the medication cart with a single lock and was not stored in the double locked drawer on the cart.

Based on observations of the facility physical plant and resident record review, the facility failed to ensure that medications kept in resident rooms are stored in an out of sight place for residents whose uniform assessment instrument ( UAI

Based on resident record review, audit of the facility medication carts and staff interviews, the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. The record for resident 7 has a physician order for Gabapentin 100mg three times a day. The November 2025 medication administration record ( MAR

Based on observations of the facility medication cart, the facility failed to ensure that over-the-counter medications were labeled with a residents name. EVIDENCE: 1. At approximately 12:15pm on the day of on-site inspection, 2 licensing inspectors )LIs) observed a bottle of Equate Multi-vitamin Mens 50+, and a bottle of Spring Valley Super Vitamin B Complex in the second drawer of the facility medication cart. The bottles were labeled with a time but were not labeled with a resident name.

Based on resident record review, the facility failed to ensure that all required information was included on resident medication administration records ( MAR

Based on resident record reviews and staff interviews, the facility failed to ensure that a residents physician was notified or recommendations made with a medication review. EVIDENCE: 1. The record for resident 1 has documentation of a medication regimen review-Note to attending Physician dated 07/02/2025. The review indicates that resident 1 is taking Escitalopram 10mg QD to manage behaviors, stabilize mood or treat a psychiatric disorder, recommend review residents current condition and consider tapering medication to evaluate if resident is on the lowest possible dose, or continue to need the medication. The review also has documentation that if resident is stable on current regimen, recommend reducing dose to Escitalopram 5mg QD and monitor for continued efficacy. The record for resident 1 does not have documentation that this recommendation was sent to the residents physician for review/consideration. In an interview with 2 Licensing Inspectors (LIs) and staff persons 1 and 5 on the day of on-site inspection, it was explained that the medication recommendation has not been sent to resident 1?s physician for review. 2. The record for resident 2 has documentation of a medication regimen review-Note to attending Physician dated 07/02/2025. The review indicates that resident 2 is taking Citalopram 40mg QAM, FDA has recently revised its recommendation for Citalopram, the maximum recommended dose for Citalopram is 20mg per day for patients older than 60 years of age, please consider changing residents dose to Citalopram 20mg QAM. In an interview with 2 LIs and staff persons 1 and 5 on the day of on-site inspection, it was explained that the medication recommendation has not been sent to resident 2?s physician for review/consideration.

Based on observations of the facility physical plant, the facility failed to maintain the interior on good repair. EVIDENCE: 1. The flooring from the sitting room into the sunroom was noted to have an area that is raised/bowing.

Based on facility documentation review, the facility failed to ensure that a review of the facility plan for resident emergencies was reviewed at least every six months with all staff. EVIDENCE: 1. The last review of the facility plan for resident emergencies with staff conducted on 09/18/2025 does not have documentation that the plan for missing resident emergencies was reviewed.

Based on facility documentation review, the facility failed to ensure that at least once every six months, an exercise in which the procedures for resident emergencies are practiced with all staff currently on duty on each shift. EVIDENCE: 1. On the day of on-site inspection, documentation of an exercise in which the procedures for resident emergencies are practiced with all staff on duty on each shift was not available for review.

Based on staff record review, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: 1. The record for staff person 2, hired on 11/03/2025, did not contain a sworn statement or affirmation as of the day of on-site inspection. 2. On the day of on-site inspection, the facility was unable to provide a sworn statement or affirmation for staff person 4 for the licensing inspector to review. Staff person 4 is listed as working in the facility on the facility?s written schedules for August, September, October and November 0f 2025.

Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff person 3, hired on 10/04/2024, did not contain a criminal history record report as of the day of on-site inspection. 2. On the day of on-site inspection, the facility was unable to provide a criminal history record report for staff person 4 for the licensing inspector to review. Staff person 4 is listed as working in the facility on the facility?s written schedules for August, September, October and November of 2025.

Based on staff record review, the facility failed to ensure that within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment. EVIDENCE: 1. The records for staff persons 1 and 2, both hired on 06/18/2024, have documentation that the employees have completed only 4 of the required 6 hours of training for individuals with cognitive impairments as of the day of on-site inspection.

Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments ( UAI

Based on resident record review, the facility failed to ensure that individualized service plans were reviewed and updated as needed when a change in a residents condition occurred. EVIDENCE: 1. The record for resident 1 has a fall risk completed on 11/05/2024 with a score of 30 to indicate that the resident is a risk for falls. The ISP

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. At 8:46am on the day of on-site inspection the LI observed the facility laundry room door to be open. The unlocked cabinets in the laundry room contained Water Flakes Bowl Cleaner, C-L Bowl Cleaner, LA?s Total Awesome Cleaner with Bleach, Window Cleaner, Great Value Disinfectant Spray and a bottle of A2Z Disinfecting Glass & Multi Surface Cleaner was sitting out on the shelf. The LI noted that staff person 1 was standing in the hallway at the medication cart outside of the laundry room but no staff were present in the laundry room at the time of observations.

Based on staff record review and staff interviews, the facility failed to ensure that written documentation of duties and responsibilities were provided to the designated person in charge prior to them being placed in charge. EVIDENCE: 1. In interviews conducted on 09/18/2024 at 8:40am by the Licensing Inspector (LI) with staff persons 1 and 2, both staff persons 1 and 2 expressed that staff person 2 was the designated person in charge at the time of this interview. 2. A dry erase board hanging in the hallway by the computer room has documentation that staff person 2 is the designated person in charge for the second shift. 3. The record for staff person 2 did not contain documentation of written duties or responsibilities as the designated person in charge on the day of this inspection.

Based on resident record review, the facility failed to ensure that all required documentation included on a residents physical examination was completed by an independent physician. EVIDENCE: 1. The physical examination dated 08/18/2024 in the record for resident 3 has documentation that the residents ambulatory/non-ambulatory status was changed with documentation of ?she can walk to drugged at hospital to do anything? and signed by staff person 5, who is not an independent physician.

Based on resident record reviews, the facility failed to ensure that a fall risk rating was completed for residents who are assessed as assisted living level of care. EVIDENCE: 1. The public pay uniform assessment instrument ( UAI

Based on observations made of the facility medications carts, the facility failed to ensure that the storage area for medications was locked. EVIDENCE: 1. At 8:48am on 09/18/2024, the Licensing Inspector (LI) observed the facility medication cart sitting in the hall outside of the Laundry Room across from an area where residents were sitting. The cart was noted be unlocked and unattended. 2. At 8:57am the LI, in the presence of staff person 2, observed that the medication cart was sitting in the same place and was unlocked and unattended. Staff person 2 expressed that staff person 1, who was the registered medication aide (RMA) was down the hallway.

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The door to the facility Laundry Room was noted to be open at 9:00am on 09/18/2024 and the room was unattended. An unlocked cabinet in the Laundry Room was noted to contain 3 bottles of C-L Bowl Cleaner and a bottle of HRX 75 Antibacterial Heavy Duty.

Based on observations of the facility physical plant, the facility failed to ensure that residents who may be permitted to keep their own cleaning supplies or other hazardous materials stored them in an out-of-sight place so that they are not accessible to other residents. EVIDENCE: 1. The door to room 12 was noted to be open at 8:50am on 09/18/2024 and the room was unattended. A bottle of Luxury 100% Acetone Nail Polish Remover was observed sitting out on the top of a small refrigerator in the room.

Based on resident record review, the facility failed to ensure that the health care service needs of a resident were met. EVIDENCE: 1. A facility incident report dated 07/28/2024 has documentation that resident 1 has a fall on 07/28/2024 and was sent to the local emergency room. 2. The record for resident 1 has a Hospital summary dated 07/29/2024 with documentation on page 2 under Medical Decision Making that states ?Left shoulder films obtained to eval for shoulder fracture which resulted in no evidence of fracture though does show findings suggestive of possible rotator cuff injury. Will place in sling and referral to orthopedic surgery to evaluate this as outpatient?. 3. The record for resident 1 does not have any documentation that the resident has been seen by an orthopedic surgeon for an evaluation for a rotator cuff injury.

Based on observations of the facility physical plant, the facility failed to ensure that interior areas were adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. The lights in the ceiling of room 12 were noted to be inoperable on the day of inspection. The second light in the room was noted to have tape holding the light cover in place.

Based on observations of the facility physical plant, the facility failed to ensure that grab bar s were located by all toilets. EVIDENCE: 1. The bathroom in room 12-A did not contain a grab bar by the toilet on the day of inspection.

Based on observations of the facility physical plant, the facility failed to ensure that the fire and emergency evacuation drawings contained all required information. EVIDENCE: 1. The fire and emergency evacuation drawing posted in the facility did not contain documentation of the areas of refuge or assembly areas.