Fork Mountain North Assisted Living Facility
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State Inspection History
State Inspections
Source: VA State Licensing Agency
Nov 20, 2025Complaint
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2025 09:40 to 12:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/6/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Based on facility digital platform review, resident record reviews and staff interviews, the facility failed to ensure that any volunteers used shall have qualifications appropriate to the services they render and be subject to laws and regulations governing confidential treatment of personal information. EVIDENCE: 1. Licensing Inspector observed the Fork Mountain North ALF digital platform website with personal information available for Resident 1, Resident 2, Resident 3 that was posted on 9/5/2025 and 10/19/2025 and Resident 4 on 11/1/2025. 2. Interview with Staff 2 and Staff 3 that the facility did not have any record of Volunteer 1 qualifications appropriate to the services rendered. Staff 2 and Staff 3 confirmed Volunteer 1 did activities with the residents such as Bingo, parties, and coordinated the efforts for donations for the residents including posting on social media on a public page and having access to their personal information. 3. Interview with Staff 2 and Staff 1 confirmed Volunteer 1 was associated with the posted personal information on Resident 1, Resident 2, and Resident 3 of their name, date of birth and clothing sizes, on 9/5/2025 and 10/19/2025 on the facility?s social media website. 4. Interview with Staff 3 confirmed Volunteer 1 was associated with the posted private health information on Resident 4 on or around 11/1/2025 on the facility?s social media website.
Based on staff interviews, the facility failed to ensure that the facility shall maintain all required documentation on volunteers. EVIDENCE: 1. Interview with Staff 2 and Staff 3 confirmed that Volunteer 1 did activities with the residents such as Bingo, parties, and coordinated the efforts for donations for the residents. Interview with Staff 2 and Staff 3 confirmed the facility did not have a record with documentation for Volunteer 1 that included all required information.
Based on staff interviews, the facility failed to ensure that prior to beginning volunteer service, all volunteers shall attend an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Volunteers shall sign and date a statement that they have received and understand this information. EVIDENCE: 1. Interview with Staff 2 confirmed the facility did not provide an orientation for Volunteer 1 and did not have a statement signed and dated by Volunteer 1 that they had received and understand the information.
Based on resident record review and staff interviews, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument ( UAI
Based on resident record reviews and staff interviews, the facility failed to ensure that only under the allowable circumstances is a facility permitted to release information from the resident's records or information regarding the resident's personal affairs without the written permission of the resident or his legal representative, where appropriate. EVIDENCE: 1. Licensing Inspector observed the Fork Mountain North ALF digital platform website with personal information available for Resident 1, Resident 2, Resident 3 that was posted on 9/5/2025 and 10/19/2025 and Resident 4 on 11/1/2025. 2. Resident 1, Resident 2, Resident 3, and Resident 4 records did not contain signed consent to release information forms to provide permission for the facility to post personal information on social media platforms or provide the personal information to any volunteers of the facility. 3. Interview with Staff 1, Staff 2, and Staff 3 confirmed the facility had posted personal information on a public social media platform for Resident 1, Resident 2, Resident 3 on 9/5/2025 and 10/19/2025 and Resident 4 on 11/1/ 2025. Staff 2 and Staff 3 confirmed Volunteer 1 was provided some access to Resident 1, Resident 2, Resident 3, and Resident 4 personal information
Oct 14, 2025Routine10Report
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/14/2025 08:30 to 15:30 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication Cart Audit, Lunch Meal Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Based on staff record review and staff interview, 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, and the training shall meet the requirements of subsection C of this section. 1. The facility serves a mixed population of residents. 2. Staff 3 record, date of hire 2/25/2025, contained documentation for attending 1 hour of training in working with individuals who have a cognitive impairment. Staff 3 is a direct care staff member. 3. Interview with Staff 1 confirmed Staff 3 record to be current.
Based on physical plant observation and staff interview, the facility failed to ensure that doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. 1. The facility serves a mixed population of residents. 2. The Licensing Inspector (LI) observed that the door by the laundry room, the door by room 122, the door by room 102, and the two doors by Suite A were not alarming and all lead to the outside of the facility. 3. Interview with Staff 6 confirmed that the battery needed to be changed and the doors were not alarming as required.
Based on staff record review and staff interview, the facility failed to ensure that ach staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free 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. EVIDENCE: 1. Staff 4 has the most current tuberculosis risk assessment dated 9/16/2024. 2. Interview with Staff 1 confirmed Staff 4 record was current.
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. 1. Staff 3, date of hire 2/25/2025, does not have current certification in first aid. Staff 3 is a direct care staff member. 2. Interview with Staff 1 confirmed Staff 3 record was current.
Based on resident record review and staff interview, the facility failed to ensure that a risk assessment for tuberculosis shall be 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: 1.Resident 2 record contained a tuberculosis risk assessment, dated 2/15/2024, as the most current assessment. 2. Interview with Staff 1 confirmed Resident 2 record to be current.
Based on resident record review and staff interview, the facility failed to ensure that the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. EVIDENCE: 1. Resident 1 record, date of admission 11/6/2024, contained a sex offender search results dated 12/12/2024. 2. Interview with Staff 1 confirmed Resident 1 record was current.
Based on physical plant observation and staff interview, the facility failed to ensure that visiting hours shall not be restricted, except by a resident when it is the resident's choice. EVIDENCE: 1. The Licensing Inspector (LI) observed a sign on the front desk that stated Visitation 8am ? 8pm. 2. Interview with Staff 2 confirmed the sign was accurate with the facility allowing visitation from 8am to 8pm, therefore restricting visiting hours for all residents.
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. Resident 3 record contained physicians order dated 9/25/205, with documentation for Aspart Insulin VL100U/ML 10 Inject 4 Units Subcutaneously 2 times a day. Hold for Glucose <150. 2. Resident 3 record contained a September and October 2025 Medication Administration Record ( MAR
Based on staff interview, the facility failed to ensure that the facility 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. The review shall be documented by signing and dating. EVIDENCE: 1. Interview with Staff 1 confirmed the facility had not completed a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers.
Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report shall be obtained within 30 days of employment for each employee. EVIDENCE: 1. Staff 3, date of hire 2/25/2025, has a criminal record check dated 4/17/2025. 2. Interview with Staff 2 confirmed this was the current criminal record check for staff 3.
Oct 14, 2025ComplaintCleanReport
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/14/2025 08:30 to 15:30 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/14/2025 regarding allegations in the area(s) of: Administrative and Administration Services and Admission, Retention, and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Aug 28, 2025ComplaintCleanReport
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/28/2025 11:45 to 13:15 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/22/2025 regarding allegations in the area(s) of: Admin and Admin Services, Admission, Discharge, and Retention of Residents, Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Jun 25, 2025Complaint
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/25/2025 11:00am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/20/2025 regarding allegations in the area(s) of: Resident care and related services. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Based on resident record review, the facility failed to ensure that individualized service plans ( ISP
Based on resident record review and observations, the facility failed to ensure that a resident?s record contained physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order and that orders were organized chronologically in the resident's record. EVIDENCE: 1. During an on-site inspection conducted on 06/25/2025 the licensing inspector (LI) requested the record for resident 1 for review. During the review the LI was unable to locate several physician orders in the record for resident 1. The LI asked staff person 1 for the additional physician orders for resident 1 and observed several large piles of paperwork sitting out on a desk and on the shelf in the administrative office that contained physician orders/progress notes and other medical documentation for multiple residents that staff person 1 was looking through to find additional physician orders for resident 1.
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician instructions. EVIDENCE: 1. A physician progress note with a date of service as 06/11/2025 and electronically signed by the physician on 06/12/2025 has documentation of the resident being prescribed Buspar 5mg twice daily for Anxiety, Prolixin Deconate 25mg per ml intramuscularly every 21 days for Bipolar, Trazadone 100mg at bedtime for Insomnia and Diphenhydramine 25mg, 2 caps every 6 hours as needed for Anxiety. The June 2025 medication administration record ( MAR
Based on resident record view, the facility failed to ensure that all required documentation was included on medication administration records ( MAR
Jan 29, 2025Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/29/2025 10:30 to 12:50 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Based on resident record review, facility record review, and staff interview, the facility failed to follow their medication management plan in regard to the ensuring of verifying that medication orders have been accurately transcribed to medication administration records ( MAR
Nov 26, 2024ComplaintCleanReport
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/26/2024 12:00 to 12:30 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/18/2024 regarding allegations in the area(s) of: Admin and Admin Services, Resident Care and Related Services Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Nov 14, 2024Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/14/2024 10:40 to 12:45 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met. EVIDENCE: 1. Resident 1 record contained a signed physician?s order, dated 11/6/2024, with documentation for HHS (home health services) to evaluate wound to left ankle as soon as possible 2-3x/week. A subsequent physician?s order in resident 1 record, dated 11/13/2024, contained documentation for please have home health services (nursing/wound care) to evaluate wound to left ankle 2-3x/week ? ordered also on 11.6.2024. If unable to have home health services this week, patient needs to be sent to wound clinic. Resident 1 record did not contain a documented, written referral or documented verbal referral to a home health service. 2. On 11/14/2024 during an interview with the licensing inspector and staff 1, staff 1 confirmed there was not written documentation for a verbal or written referral for home health services from the facility. Staff 1 reported that home health was supposed to start today, 11/14/24, for resident 1.
Based on resident record review, the facility failed to ensure a resident's need for skilled nursing treatments within the facility was met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse. EVIDENCE: 1. During an on- site inspection on 10/16/2024, it was discovered that staff 1 and staff 2, both Registered Medication Aides, had been completing a physician ordered treatment, dated 8/12/2024, for a lower extremity wound for resident 1 that should have been completed by licensed healthcare professionals between 8/12/2024 through 10/13/2024. This non-compliance with the regulation was revealed to staff 3 on 10/16/24, and staff 4 on 10/18/24. 2. Resident 1 record contained an October 2024 Medication Administration Record ( MAR
Based on resident record review and staff interview, the facility failed to ensure that whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility and ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. EVIDENCE: 1. Resident 1 record contained an After Visit Summary from a local hospital with documentation that the resident was admitted to the hospital on 10/13/2024 and discharged on 10/17/2024 due to a small bowel obstruction. There is no documentation in the resident?s record that the facility obtained new orders for all medications and treatments prior to or at the time of the resident?s return to the facility and that the primary physician was aware of all medication orders with documentation of the contact with the physician regarding the new orders. 2. Resident 1 record contained an October 2024 Medication Administration Record with notation that the resident was in the hospital on 10/13/2024 to 10/17/2024. 3. On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed there was no documentation of new orders from the physician upon the return of the resident or prior to their return, and that the primary physician was aware of all medication orders with documentation of the contact.
Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff 5 record, date of hire 7/4/2024, did not contain a criminal history record report. 2. Staff 2 record, date of hire 6/18/2024, did not contain a criminal history record report. 3. During an on-site inspection on 10/16/2024, the facility did not have the criminal history reports for staff 5 and staff 2. According to a plan of correction for this noncompliance submitted by the facility, the facility was to correct this on 10/16/2024. 3. On the day of inspection during an interview with the licensing inspector and staff 6, staff 6 confirmed that the facility had not received the criminal history record reports and therefore were not in the files for staff 5 and staff 2. Staff 6 revealed that the facility had mailed a check to the Virginia State Police on 10/25/2024 for the background checks, however, had no documentation to support that this check was specific for the background checks for staff 5 and staff 2.
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