Holston Senior Living

Based on a review of resident records, the facility failed to ensure that in order to be admitted or retained in a safe, secure environment as defined in 22VAC40- 73-10, except as provided in subsection B of this section, a resident must have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safety and welfare. EVIDENCE: 1. According to 22VAC40-73-10, ?serious cognitive impairment" means severe deficit in mental capability of a chronic, enduring, or long-term nature that affects areas such as thought processes, problem solving, judgment, memory, and comprehension and that interferes with such things as reality orientation, ability to care for self, ability to recognize danger to self or others, and impulse control. For the purposes of this chapter, serious cognitive impairment means that an individual cannot recognize danger or protect the individual?s own safety and welfare. 2. According to 22VAC40-73-10, "Ambulatory" means the condition of a resident who is physically and mentally capable of self-preservation by evacuating in response to an emergency to a refuge area as defined by 13VAC5-63, the Virginia Uniform Statewide Building Code, without the assistance of another person, or from the structure itself without the assistance of another person if there is no such refuge area within the structure, even if such resident may require the assistance of a wheelchair, walker, cane, prosthetic device, or a single verbal command to evacuate, and ?nonambulatory? means the condition of a resident who by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person. 3. Resident #1 was admitted to the safe, secure environment on 02/17/2026. The report of resident physical examination for resident #1, dated 02/12/2026, indicates he is ambulatory. The comprehensive individualized service plan ( ISP

Based on record review and staff interview, the facility failed to ensure that within 30 days preceding admission, a person shall have a physical examination by an individual physician that contains all required information. EVIDENCE: 1. On the date of inspection, the record for resident #7 contained a series of pages, dated 01/06/2026, which indicate that they are the H & P (history and physical) documents for the resident. Upon review of that documentation, the following required information for the resident was not identified: THE PERSON?S ADDRESS AND PHONE NUMBER, ANY RECOMMENDATIONS FOR CARE INCLUDING DIET TYPE, RESULTS OF A TUBERCULOSIS RISK ASSESSMENT, A STATEMENT THAT THE PERSON DOES NOT HAVE ANY PROHIBITED CONDITIONS OR CARE NEEDS, A STATEMENT THAT SPECIFIES WHETHER THE PERSON IS CONSIDERED TO BE AMBULATORY OR NONAMBULATORY, and A STATEMENT THAT SPECIFIES WHETHER THE INDIVIDUAL CAN OR CANNOT SELF-ADMINISTER MEDICATION. 2. On the date of inspection, the record for resident #8 contained a series of pages, dated 09/17/2025, which indicate that they are the H &P documents for the resident. Upon review of that documentation, the following required information for the resident was not identified: THE PERSON?S ADDRESS AND PHONE NUMBER, RESULTS OF A TUBERCULOSIS RISK ASSESSMENT, A STATEMENT THAT THE PERSON DOES NOT HAVE ANY PROHIBITED CONDITIONS OR CARE NEEDS, and A STATEMENT THAT SPECIFIES WHETHER THE INDIVIDUAL CAN OR CANNOT SELF-ADMINISTER MEDICATION. 3. An interview with staff #4 on the date of inspection was unsuccessful at locating the missing required physical examination information for those two residents.

Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. EVIDENCE: 1. Resident #8 was admitted to the facility on 11/15/2025; the sex offender registry was checked on 11/19/2025.

Based on record review and staff interview, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, there shall be specific personal and social information obtained on a person. EVIDENCE: 1. On the date of inspection, the record for resident #7 contained a RESIDENT ? PERSONAL/SOCIAL DATA form that did not contain documentation in the following areas: ADMISSION DATE, INTERESTS/HOBBIES, LIFETIME VOCATION, CAREER OR PRIMARY ROLE, CURRENT BEHAVIORAL AND SOCIAL FUNCTIONING (STRENGTHS AND PROBLEMS), and SUBSTANCE ABUSE HISTORY (IF APPLICABLE FOR CARE OR SERVICES). 2. On the date of inspection, the record for resident #8 contained a RESIDENT ? PERSONAL/SOCIAL DATA form that did not contain documentation in the following areas: ADMISSION DATE, ALLERGIES, PERSONAL DENTIST, PREVIOUS MENTAL HEALTH OR INTELLECTUAL DISABILITY SERVICES HISTORY (IF APPLICABLE FOR CARE OR SERVICES), and CURRENT BEHAVIORAL AND SOCIAL FUNCTIONING (STRENGTHS AND PROBLEMS). 3. On the date of inspection, the record for resident #1 contained a RESIDENT ? PERSONAL/SOCIAL DATA form that did not contain documentation in the following areas: ADMISSION DATE, ALLERGIES, LIFETIME VOCATION, CAREER OR PRIMARY ROLE, SERVICE IN THE ARMED FORCES, IF APPLICABLE, INFORMATION ON ADVANCE DIRECTIVES, DO NOT RESUCSITATE (DNR) ORDERS, OR ORGAN DONATION, IF APPLICABLE, LEGAL REPRESENTATIVE, IF ANY, RESPONSIBLE INDIVIDUAL, IF NEEDED, CLERGYMAN/PLACE OF WORSHIP, IF APPLICABLE, and OTHER AGENCY, IF APPLICABLE. 4. On the date of inspection, the record for resident #3 contained a RESIDENT ? PERSONAL/SOCIAL DATA form that did not contain documentation in the following areas: BIRTH PLACE, LIFETIME VOCATION, CAREER OR PRIMARY ROLE, SERVICE IN THE ARMED FORCES, IF APPLICABLE, CLERGYMAN/PLACE OF WORSHIP, IF APPLICABLE, PERSONAL DENTIST and LOCAL DEPARTMENT OF SOCIAL SERVICES, IF APPLICABLE. 5. An interview with staff #4 on the date of inspection was unsuccessful at locating the missing personal and social information for those four residents.

Based on record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument ( UAI

Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan ( ISP

Based on record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the licensed hospice care organization shall communicate and establish an agreed upon coordinated plan of care for the resident, and the services provided by each shall be included on the individualized service plan ( ISP

Based on a review of facility documentation, the facility failed to implement its written plan for medication management. EVIDENCE: 1. According to the facility?s controlled medication management plan under item #4, ?at each change of shift, the licensed person who has had the keys to the narcotics storage will count each dose of narcotics with the oncoming, licensed staff person. Both employees will sign the count sheets.? 2. Missing on/off staff initials were observed on the Total Narc Card Count Sheets in the blue three ring binder located in the safe, secure environment on the following dates: 02/25/2026, 02/26/2026, 03/01/2026, 03/04/2026, 03/05/2026, 03/09/2026, 03/10/2026, 03/11/2026, 03/12/2026, 03/13/2026, 03/16/2026 and 03/18/2026. 3. Missing on/off staff initials were observed on the Total Narc Card Count Sheets in the red three ring binder located in the safe, secure environment on the following dates: 02/28/2026, 03/02/2026, 03/04/2026, 03/08/2026, 03/09/2026, 03/11/2026, 03/13/2026 and 03/16/2026.

Based on a review of resident records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. The record for resident #5 contains the following order, dated 12/19/2025: Lantus Solostar 100 unit/mL; Inject 5 units sub-q daily at bedtime *Hold if BS (blood sugar) less than 200. 2. The March 2026 medication administration record ( MAR

Based on observation and staff interview, the facility failed to ensure that the original container for storing over-the-counter (OTC) medication shall be labeled with the resident?s name. EVIDENCE: 1. On the date of inspection, during an audit of the 2nd floor medication cart at around 10:35 AM, the LI observed that in the 2nd drawer down in the middle and on the right side, there was an OTC bottle of VITAMIN B-12 1000 MCG and an OTC bottle of ALIGN PROBIOTIC that did not contain a resident name. 2. In the 3rd drawer down, on the right side, there were approximately 27 additional bottles of OTC medications and supplements, most of which did not contain the name of the resident that they were prescribed to. 3. An interview with staff #1, at the time of observation, revealed that a request had been made by the facility for the OTC medications and supplements that did not contain resident names, to be repackaged by the pharmacy. 4. Per staff #1, until the repackaged medications arrive at the facility, the OTC medications and supplements without names were being used for any resident who has a physician?s order for that OTC medication or supplement.

Based on a tour of the building, 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: 1. In the bathroom for resident room #372, the paint on the lower portion of the wall between the shower and the sink was peeling, and there were dark spots observed on the paint just above the base board. The baseboard was also missing. 2. In the bathroom for resident room #368, the paint on the lower portion of the wall between the shower and the sink was peeling.

Based on a tour of the building, 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: 1. The toilet seat in the bathroom for resident room #359 was loose and easily moved side to side according to resident #9. 2. The ceiling mounted heater in the bathroom for resident room #371 did not work when switched on.

Based on observations made during the tour of the safe, secure environment, the facility failed to ensure special precautions were taken to make sure ordinary objects or materials which may be harmful to this population were inaccessible to the resident except under staff supervision. EVIDENCE: 1. Four AA batteries, and four nutrition shakes in were observed in the room for resident #12. 2. Three different hair products and a bottle of nail polish remover was observed in the room for resident #13, in her storage area under her refrigerator.

Based on observations made during the noon medication pass, the facility failed to implement their infection prevention measures by staff to include means to ensure hand hygiene. EVIDENCE: 1. During the medication pass in the safe, secure environment observed by the licensing inspector on 12/10/2025, staff #2 did not wash her hands prior to administering medications.

Based on a review of resident records, the facility failed to ensure written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative shall be retained in the resident's record. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2025; there was no documentation in the record indicating a disclosure statement provided to the resident. 2. Resident #2 was admitted to the facility on 10/16/2025; there was no documentation in the record indicating a disclosure statement provided to the resident. 3. Resident #3 was admitted to the facility on 10/16/2025; there was no documentation in the record indicating a disclosure statement provided to the resident. 4. Resident #4 was admitted to the facility on 10/16/2025; there was no documentation in the record indicating a disclosure statement provided to the resident. 5. Resident #5 was admitted to the facility on 10/16/2025; there was no documentation in the record indicating a disclosure statement provided to the resident. 6. Resident #6 was admitted to the facility on 10/16/2025; there was no documentation in the record indicating a disclosure statement provided to the resident.

Based on a review of staff records, the facility failed to ensure that the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. 1. The date of hire for staff #1 was 10/16/2025; there was no documentation of orientation that occurred within the first seven working days of employment. 2. The date of hire for staff #2 was 10/16/2025; there was no documentation of orientation that occurred within the first seven working days of employment. 3. The date of hire for staff #2 was 10/16/2025; there was no documentation of orientation that occurred within the first seven working days of employment.

Based on a review of staff records, the facility failed to ensure that prior to being placed in charge, the staff member shall be informed of and receive training on his or her duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. According to staff #7, staff #2 is in charge at times in the safe, secure environment. 2. There was no documentation observed in the record for staff #2 indicating she had been informed of and received training on duties and responsibilities when in charge and provided written documentation of such.

Based on a review of staff records, the facility failed to ensure personal and social data is maintained on all staff and included in the staff record. EVIDENCE: 1. The records for staff #1, #2, #7, #10, and numbers 12 through 31 did not contain an original criminal record report. 2. The record for staff #3 did not contain the following: Current address and telephone number; position title and date employed; verification that the staff person has received a copy of his current job description; an original criminal record report and a sworn disclosure statement; and, name and telephone number of person to contact in an emergency.

Based on a review of staff records, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the 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. EVIDENCE: 1. The date of hire for staff #1 was 10/16/2025; the record for staff #1 did not contain the results of a risk assessment, documenting the absence of tuberculosis in a communicable form within seven days prior to the first day of work at the facility. 2. The date of hire for staff #2 was 10/16/2025; the record for staff #2 did not contain the results of a risk assessment, documenting the absence of tuberculosis in a communicable form within seven days prior to the first day of work at the facility.

Based on a review of staff records, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The date of hire for staff #2 was 10/16/2025. 2. Staff #2 currently works in the safe, secure environment. There was no documentation in the file for staff #2 of training in methods of dealing with aggressive behaviors prior to being involved in the care of such residents.

Based on a review of staff records, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The date of hire for staff #2 was 10/16/2025. 2. Staff #2 currently works in the safe, secure environment. There was no documentation in the file for staff #2 of training in methods of dealing with aggressive behaviors prior to being involved in the care of such residents.

Based on a review of resident records, the assisted living facility administrator failed to provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission and to maintain a copy signed by the resident or his legal representative in the resident's record. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2025; a copy of the written assurance was not available in the record for resident #1. 2. Resident #2 was admitted to the facility on 10/16/2025; a copy of the written assurance was not available in the record for resident #2. 3. Resident #3 was admitted to the facility on 10/16/2025; a copy of the written assurance was not available in the record for resident 3. 4. Resident #4 was admitted to the facility on 10/16/2025; a copy of the written assurance was not available in the record for resident #4. 5. Resident #5 was admitted to the facility on 10/16/2025; a copy of the written assurance was not available in the record for resident #5. 6. Resident #6 was admitted to the facility on 10/16/2025; a copy of the written assurance was not available in the record for resident #6.

Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender and to document in the resident's record that this was ascertained and the date the information was obtained. EVIDENCE 1. Resident #1 was admitted to the facility on 10/16/2025; there was no documentation in the record for resident #1 that the facility ascertained whether the resident is a registered sex offender prior to admission. 2. Resident #2 was admitted to the facility on 10/16/2025; there was no documentation in the record for resident #2 that the facility ascertained whether the resident is a registered sex offender prior to admission. 3. Resident #3 was admitted to the facility on 10/16/2025; there was no documentation in the record for resident #3 that the facility ascertained whether the resident is a registered sex offender prior to admission. 4. Resident #4 was admitted to the facility on 10/16/2025; there was no documentation in the record for resident #4 that the facility ascertained whether the resident is a registered sex offender prior to admission. 5. Resident #5 was admitted to the facility on 10/16/2025; there was no documentation in the record for resident #5 that the facility ascertained whether the resident is a registered sex offender prior to admission. 6. Resident #6 was admitted to the facility on 10/16/2025; there was no documentation in the record for resident #6 that the facility ascertained whether the resident is a registered sex offender prior to admission.

Based on a review of resident records, the facility failed to ensure that at or prior to the time of admission, there shall be a written agreement or acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2025; there was no documentation of a signed and dated written agreement or acknowledgement thereof. 2. Resident #2 was admitted to the facility on 10/16/2025; there was no documentation of a signed and dated written agreement or acknowledgement thereof. 3. Resident #3 was admitted to the facility on 10/16/2025; there was no documentation of a signed and dated written agreement or acknowledgement thereof. 4. Resident #4 was admitted to the facility on 10/16/2025; there was no documentation of a signed and dated written agreement or acknowledgement thereof. 5. Resident #5 was admitted to the facility on 10/16/2025; there was no documentation of a signed and dated written agreement or acknowledgement thereof. 6. Resident #6 was admitted to the facility on 10/16/2025; there was no documentation of a signed and dated written agreement or acknowledgement thereof.

Based on a review of resident records, the facility failed to ensure that upon admission, an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system shall be provided resident and, as appropriate, his legal representative, and to maintain signed and dated acknowledgment of having received the orientation in the resident's record. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2025; there was no acknowledgement of having received an orientation in the record. 2. Resident #2 was admitted to the facility on 10/16/2025; there was no acknowledgement of having received an orientation in the record. 3. Resident #3 was admitted to the facility on 10/16/2025; there was no acknowledgement of having received an orientation in the record. 4. Resident #4 was admitted to the facility on 10/16/2025; there was no acknowledgement of having received an orientation in the record. 5. Resident #5 was admitted to the facility on 10/16/2025; there was no acknowledgement of having received an orientation in the record. 6. Resident #6 was admitted to the facility on 10/16/2025; there was no acknowledgement of having received an orientation in the record.

Based on a review of resident records, the facility failed to ensure the uniform assessment instrument ( UAI

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

Based on resident record review, the facility failed to include hospice services provided on the Individualized Service Plan ( ISP

Based on resident record review, the facility failed to have the Individualized Service Plan ( ISP

Based on resident record review, the facility failed to review and updated individualized service plans ( ISP

Based on staff interview, the facility failed to ensure that the resident?s individualized service plan ( ISP

Based on a review of staff records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person, including written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. EVIDENCE: 1. The date of hire for staff #1 was 10/16/2025; there was no documentation of resident rights review observed in the record for staff #1 following the date of hire. 2. The date of hire for staff #2 was 10/16/2025; there was no documentation of resident rights review observed in the record for staff #2 following the date of hire. 3. The date of hire for staff #3 was 10/16/2025; there was no documentation of resident rights review observed in the record for staff #3 following the date of hire. 4. The date of admission for resident #1 was 10/16/2025; there was no documentation of resident rights review observed in the record for resident #1 following the date of admission. 5. The date of admission for resident #2 was 10/16/2025; there was no documentation of resident rights review observed in the record for resident #2 following the date of admission. 6. The date of admission for resident #4 was 10/16/2025; there was no documentation of resident rights review observed in the record for resident #4 following the date of admission. 7. The date of admission for resident #5 was 10/16/2025; there was no documentation of resident rights review observed in the record for resident #5 following the date of admission. 8. The date of admission for resident #6 was 10/16/2025; there was no documentation of resident rights review observed in the record for resident #6 following the date of admission.

Based on observations made during the tour of the building, the licensee failed to ensure all records are treated confidentially and that information shall be made available only when needed for care of the resident. EVIDENCE: 1. Resident #11 has a yellow sheet of paper indicating a do not resuscitate order (DNR) on the front of the door, visible in the hallway.

Based on review of physician?s orders and medication administration records ( MAR

Based on observations made during the length of the inspection, the facility failed to have physician?s or other prescriber?s orders organized chronologically in the resident?s records. EVIDENCE: 1. According to interviews with staff #1, #3, #7 and #11, there has been a recent change in pharmacy. The facility sent all physician?s orders to the pharmacy via a courier but failed to make copies of the orders prior to sending them. 2. On the first day of the inspection, no physician?s orders were available. 3. Staff #5 obtained physician's orders via fax during the second day of the inspection.

Based on observations made during the noon medication pass, the facility failed to store medications in a manner consistent with the current standards of practice. EVIDENCE: 1. During the noon medication pass while administering medication to resident #8, staff #1 left the keys in the medication cart and left the cart unlocked and unattended in the hallway while going into the resident?s room.

Based on observations made during the 11am medication pass, the facility failed to keep the medications in the pharmacy issued container with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. Staff #3 was ready to administer eye drops, gabapentin, and a blood glucose check to resident #14 at 11:01am on 12/09/2025. The licensing inspector and staff #3 walked down the hall to the room for resident #14 to find that she had already gone down to the dining room for lunch. Staff #3 was unable to administer the medication to resident #14. 2. Staff #3 returned the medications to the cart, including the gabapentin which was placed in a dosing cup.

Based on the review of the medication administration record ( MAR

Based on observations made during the review of the medication administration records ( MAR

Based on observations made during the medication cart audit, the facility failed to have medications ordered for PRN

Based on observations made during the tour of the building, the facility failed to ensure bedrooms contain all required items. EVIDENCE: 1. The room for resident #2 is occupied by two residents and had only one chair. 2. Resident room #368 is occupied by two residents but did not contain any chairs. 3. In resident room #368, the mattress on the bed closest to the window was observed to have a noticeable concave area in the center. 4. In the room for resident #5 in the safe, secure environment, there was no window covering observed.

Based on observations made during the tour of the building, the facility failed to have sufficient bed linens in good repair so that residents always have clean sheets. EVIDENCE: 1. In the room for resident #10, her fitted sheet was observed to be soiled and stained with what appeared to be blood. 2. The bed in room #309 in the safe, secure environment did not have a top sheet or a blanket. When the licensing inspector asked the resident if he used a blanket or sheet at night, he stated he did not, he just laid down and went straight to sleep.

Based on observations made during the tour of the building, the facility failed to keep the interior of the building in good repair and kept clean. EVIDENCE: 1. The carpet in the room for resident #2 was observed to be brown/black and stained throughout the room. 2. The door by the stairs on the first floor marked ?Housekeeping? was observed to have a rust/brown colored streak running all the way down the middle of the door. 3. The common room on the second floor had a grocery bag with plastic cups in a chair near the entry door; an opened, frozen meal was found sitting on top of the microwave; a chair near the window had a clear plastic bag over the seat area; a three foot section of the baseboard under the kitchen sink area was missing; a plastic bag was found tucked in the blinds in the bathroom; a three foot area between the housekeeping door and the bathroom door was not painted and had a hole in the wall where some type of fixture had been, and a section of chair railing approximately eight inches long was missing. 4. The common room on the third floor had a three-foot area between the housekeeping door and the bathroom door that was not painted.

Based on observations made during the tour of the building and during the noon medication pass, the facility failed to ensure all buildings shall be free from foul odors. EVIDENCE: 1. The room for resident #2 presented with a strong smell consistent with urine. 2. The room for resident #8 presented with a strong smell consistent with urine.

Based on observations made during the tour of the building, the facility failed to keep furnishings, fixtures and equipment clean and in good repair and condition. EVIDENCE: 1. In resident room #372, the box springs for resident #9 was observed to be stained with a dark substance.

Based on a review of staff records, the facility failed to ensure that within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section. EVIDENCE: 1. There was no record of staff training hours observed in the record for staff #2. 2. In the record for staff #3, only one hour of training in cognitive impairment within the first four months of employment was documented.

Based on a tour of the building, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. The items noted below were observed in the safe, secure environment. a. The following items were observed in resident room #301: Dial handsoap, Dove shea butter and vanillin lotion and Crest toothpaste. b. The following items were observed in resident room #303: DermaVera skin & hair cleanser, Freshmint toothpaste, Freshscent shave cream and PeriFresh perineal cleanser. c. The following items were observed in resident room #307, Derma Vera skin & hair cleanser, Freshmint mouthwash, Crest toothpaste, Luxury nail polish remover (100% acetone), Suave lotion, Ecolab clear gel hand sanitizer and Snowflakes & Cashmere lotion. d. The following items were observed in resident room #311: Natural Sense cornstarch baby powder, Equate diabetics lotion, Palmers cocoa butter lotion, two glass bottles of perfume, Polident dental appliance cleanser, Suave softening shampoo, TotalBath skin & hair cleanser, Suave conditioner and Aveeno body wash. e. In resident room #310, Freshmint toothpaste was observed. f. The following items were observed in resident room #306: DermaVera skin & hair cleanser, Vanilla Bean Noel lotion and Equate conditioner. 2. At 11:02am during the LI visit to the safe, secure environment, the following items were observed at the nurses station: Sani-Cloth bleach wipes, Germs Be Gone hand sanitizer, Sani-Cloth Germicidal wipes and four small bottles of Ecolab hand sanitizer. The door to the nurse?s station was noted to be unsecured at the time of the visit.

Based on a review of staff records, the facility failed to ensure that prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. There was no documentation observed in the record for staff #1 indicating she had been informed of and received training on duties and responsibilities when in charge, and provided written documentation of such. 2. There was no documentation observed in the record for staff #3 indicating she had been informed of and received training on duties and responsibilities when in charge, and provided written documentation of such. 3. There was no documentation observed in the record for staff #4 indicating she had been informed of and received training on duties and responsibilities when in charge, and provided written documentation of such.

Based on a review of staff records, the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EVIDENCE: 1. There was no record of staff training hours observed in the record for staff #2. 2. In the record for staff #3, from 08/15/2024 through 08/15/2025, only a total of 11.05 training hours were documented.

Based on a review of staff records, the facility failed to ensure that at least two of the required hours of training shall focus on infection control and prevention and that when adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to residents' mental impairments. EVIDENCE: 1. There was no record of staff training hours observed in the record for staff #2. 2. In the record for staff #3, from 08/15/2024 through 08/15/2025, only 1.5 hours of infection control and prevention training were documented, and only 1:18 hours of training related to mental impairments were documented.

Based on a review of staff records, the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. EVIDENCE: 1. There was no current certification in first aid observed in the record for staff #2. 2. The most recent certification in first aid observed in the record for staff #3 was due to be renewed in December 2024.

Based on a review of staff records, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. Staff #2 currently works in the safe, secure environment. There was no documentation of training in methods of dealing with aggressive behaviors prior to being involved in the care of such residents. 2. Staff #3 currently works in the safe, secure environment. There was no documentation of training in methods of dealing with aggressive behaviors prior to being involved in the care of such residents.

Based on a tour of the building, the facility failed to ensure the rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place in all assisted living facilities. EVIDENCE: 1. The LI did not observe the rights and responsibilities of residents to be posted conspicuously in a public place at the time of inspection.

Based on a review or staff records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person, including written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. EVIDENCE: 1. There was no documentation of annual resident rights review observed in the record for staff #2. 2. The most recent documented annual resident rights review for staff #3 occurred on 08/14/2024.

Based on a review of facility documents, the written medication management plan does not have approval by the department. EVIDENCE: 1. As of 10/14/2025, the facility?s written medication management plan has not been approved by the department.

Based on a tour of the building, the facility failed to ensure bedrooms shall contain all required items. EVIDENCE: 1. In the room for resident #1, there was no operable bed lamp or bedside light observed for the resident bed closest to the entrance. There were no sturdy chairs observed for either resident in the room. 2. In the room for resident #2, there was no operable bed lamp or bedside light observed for resident #2. 3. In resident room #274, there was no operable bed lamp or bedside light observed for the resident bed nearest the entrance. 4. In resident room #259, there was no operable bed lamp or bedside light observed for the resident bed nearest the entrance. 5. Resident room #325 accommodates two residents and only one sturdy chair was observed in the room. 6. Resident room #301 accommodates one resident and no sturdy chair was observed in the room.

Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In resident room #371, several stains were observed on the carpet, especially around the bed nearest to the door. In the bathroom for the same room, the paint on the lower portion of the wall between the shower and the sink was bubbling and peeling. 2. In the bathroom for resident room #376, the paint on the lower portion of the wall between the shower and the sink was peeling slightly just above the baseboard. 3. In the room for resident #1, several stains were observed on the carpet, especially in hallway by the closet. 4. In the room for resident #2, stains were observed on the carpet by the bed near the window. 5. In resident room #354, stains were observed on the carpet in the main living area. 6. In the bathroom for resident room #275, the paint on the lower portion of the wall between the shower and the sink was bubbling and peeling. 7. In resident room #278, there was a small stain on the carpet where it meets the tile flooring. 8. In the bathroom for resident room #274, large water stains were observed on the ceiling. 9. In the bathroom for resident room #256, the paint on the lower portion of the wall between the shower and the sink was bubbling and peeling and several water stains were observed on the ceiling.

Based on a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. The LI observed a strong foul odor upon walking into resident room #371. 2. The LI observed a strong foul odor resembling urine upon walking into resident room #325.

Based on a tour of the building, the facility failed to ensure all interior and exterior areas shall be adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. In the bathroom for resident room #379, only one light bulb was working in the light fixture above the mirror. The overhead light did not work when switched on. 2. In the bathroom for resident #2, only one light bulb was working in the light fixture above the mirror. The overhead light did not work when switched on.

Based on a tour of the building, the facility failed to ensure there shall be ventilation to the outside in order to eliminate foul odors. EVIDENCE: 1. In the bathroom for resident room #371, the exhaust did not work when switched on. 2. In the bathroom for resident room #376, the exhaust did not work when switched on. 3. In the bathroom for resident room #262, the exhaust did not work when switched on. 4. In the bathroom for resident room #266, the exhaust did not work when switched on.