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Source: VA State Licensing Agency
Type of inspection: Complaint An unannounced complaint inspection took place on 05/23/2025 at 9:06 am to 10:30 am. 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: 21 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents were observed in the common areas. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An other inspection completed on 05/08/2025 at 11:40 am to 12:21 pm. 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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 20 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: Facility considering request for modification for residential level of care. Resident?s UAI
Type of inspection: Renewal An unannounced renewal inspection took place on 03/25/2025 at 7:35 am until 12:55 pm. 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: 20 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch was observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, liability insurance, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or staff person. Evidence of this review shall be the resident?s or staff person?s written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the resident?s or staff person?s record. Evidence: 1. The record for resident #2 did not contains an annual review of resident?s rights and responsibilities. The resident?s rights review in the record is dated 02/23/24. 2. The record for resident #4 did not contain an annual review of resident?s rights and responsibilities. The resident?s rights review in the record is dated 08/15/23. 3. Staff #1 confirmed the records for resident #2 and resident #4 did not contain an annual review of residents rights and responsibilities.
Based on the record review and staff interview the facility failed to ensure each 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 (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff #1, hire date 06/0/2000, did not contain an annual risk assessment for TB. The risk assessment for TB in the record is dated 07/25/23. 2. Staff #1 confirmed the record for staff #1 did not contain an annual risk assessment for TB.
Based on observation and staff interview the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction labeled attached, until administered to the resident. Evidence: 1. During the tour of the facility on 03/25/25 at 7:37am, two cups located on the top of the medication cart, contained pre-poured medications. Staff #1 confirmed the medications belonged to resident #1 and resident #3. 2. Staff #1 confirmed, staff #1 removed the pills from the pharmacy issued container and placed the pills in the plastic cups and was waiting for resident #1 and resident #3 to wake up to administer the medications to the residents. .
Based on the record review and staff interview the facility failed to ensure the Medication Administration Record ( MAR
Based on the record review and staff interview the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident #2, admission date 11/03/21, does not contain an annual risk assessment for TB. The risk assessment in the record is dated 03/12/24. 2. The record for resident #4, admission date 08/05/23, does not contain an annual risk assessment for TB. The risk assessment in the record is dated 08/01/23. 3. Staff #1 confirmed the records for resident #2 and resident #4 did not contain an annual risk assessment for TB.
Based on observation and staff interview the facility failed to ensure the current month?s activity schedule shall be posted in aconspicuous location in the facility or otherwise be made available to residents and their families. Evidence: 1. The activity schedule posted in the facility was dated for January 2025. 2. Staff #1 confirmed the facility did not have a March 2025 activity schedule posted or readily available for the residents.
Based on the record review and staff interview the facility failed to ensure the facility shall have, keep current, and implement a written plan for medication management. The facility?s medication plan shall address procedures for medication and shall include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The facility?s medication management plan does not include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. 2. Staff #1 confirmed the facility?s medication management plan does not include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. 3. The facility?s ?shift change controlled substance count check sheet? was last completed on 06/24/2024. 2. Resident?s #4 controlled substance count sheet for two of the resident?s medications, Dextroamp-Amphet ER (1x daily) and Zolpidem (1x daily) does not include a count of the medications during the timeframe of 01/12/25 through 03/25/2025. 3. Resident?s #5 controlled substance count sheet for the medication, Clonazepam (3x daily) does not include a count of the medications during the timeframe of 01/12/25 through 03/25/2025. 4. Resident?s #6 controlled substance count sheet for the medication Viberzi (1x daily) does not include a count of the medication during the timeframe of 01/12/25 through 03/25/2025. 5. Staff #1 confirmed the facility?s medication aides have not documented counts of the resident?s medications that are controlled substances since 01/12/25 nor have the staff completed the ? shift change controlled substance count sheet? since 06/24/24.
Type of inspection: Monitoring An unannounced monitoring inspection took place on 01/13/2025 at 12:46 pm until 01:40 pm. 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed in the common areas. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #1, hire date of 11/22/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work.
Based on the onsite record review, it was determined that the facility failed to ensure the orientation and training required in subsection B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #1, hire date 11/22/24, did not contain documentation of an orientation and training. 2.Staff #2, was unable to provide documentation during the onsite inspection that the orientation and training was completed for staff #1.
Type of inspection: Monitoring An unannounced monitoring inspection took place on 10/03/24 at 11:25 am until 11:37 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 9/17/24 regarding allegations in the area of: Personnel Number of residents present at the facility at the beginning of the inspection: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch was observed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the staff interview the facility failed to ensure the facility shall have an administrator of record. Evidence: 1. During a phone call with staff #1 on 9/17/24, staff #1 reported staff #2?s assisted living facility administrator license was suspended by the Virginia Board of Long-term Care administrators during a formal hearing held on 9/17/24. 2. During an onsite inspection on 10/03/24, staff #1 confirmed the facility is operating without an administrator licensed by the Virginia Board of Long- Term Care Administrators.
Type of inspection: Renewal An unannounced renewal inspection took place on 03/28/2024 at 08:32 am until 03:45 pm. 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: 21 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on observation and interview, it was determined that the facility failed to ensure that all resident records shall be kept in a locked area, except that information shall be made available as noted in subsection F of this section. Evidence: 1. The following binders were observed and reviewed in the common area of the facility: Medication Pharmacy Review Binder, Home Health Notes, Incident Report logs, List posted with residents? names, social security number and date of birth posted. 2. Staff #5 was present and confirmed that the binders should be stored in locked area.
Based on the onsite record review, and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #7, discharge date 12/25/2023, contains the following: a progress note dated 12/25/23 that documents a medical emergency for the resident to include a call to 911; a discharge statement for the resident?s death that occurred on 12/25/23. No incident report of the resident?s medical emergency and death was provided to the Licensing Inspector. 2. The facility?s emergency plan includes to report medical emergencies to ?DSS Licensing office the next day.? Staff #5 was unable to provide evidence of reporting to DSS, resident?s #7 medical emergency and death.
Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During the medication pass observation with staff #3, Staff #3 left the medication cart unlocked in the common area while administering medications to resident #9 in the resident?s room. 2. Staff # 3 was assigned to the medication cart, and the key to the medication cart was observed to be inserted into the lock/unlock device on the medication cart.
Based on observation and interview, it was determined that the facility did not ensure that all records are treated confidentially, and that information shall be made available only when needed for care of the resident. Evidence: 1. The following binders, which contained confidential information, were observed, and reviewed in the common area of the facility: Medication Pharmacy Review Binder, Home Health Notes, Incident Report logs, List posted with residents? names, social security number and date of birth posted. 2. Staff #5 was present and confirmed that the binders contained confidential information.
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: An unannounced renewal inspection took place on 03/28/2023 at 08:32 am until 03:45 pm. 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: 21 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are licensed health care professionals or certified nurse?s aides shall attend at least 12 hours of annual training. Evidence: 1. The record for staff #1, a certified nurse?s aide, hire date 08/31/21 documents 10.5 hours of annual training during the timeframe of 08/31/21-08/31/22.
Based on the record review the facility failed to ensure a listing of all staff who have current certification in first aid or CPR shall be posted in the facility, Evidence: 1. During a tour of the facility a listing of all staff who have current certification in first aid or CPR was not observed to be posted in the facility. 2. Staff #4 acknowledged a listing of all staff who have current certification in first aid or CPR was not posted in the facility.
Based on the record review the facility failed to ensure the Uniform assessment instrument ( UAI
Based on the record review the facility failed to ensure a risk assessment for (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident #1 contains a risk assessment for TB dated 01/20/22. The resident?s record does not contain an annual risk assessment for TB completed after 01/20/22.
Based on the record review the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: 1. The record for resident #1, admission date of 02/18/22, contains a physical examination dated 12/17/2021 which is more than 30 days prior to the resident?s admission date.
Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. During a tour of the facility a posting of the on-site person in charge was not observed to be posted in the facility. 2. Staff #4 acknowledged a posting of the on-site person in change was not posted in the facility.
Based on observation the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During a tour of the facility with staff #2 the medication cart was observed to be unlocked. 2. The key to the medication cart was observed to be inserted into the lock/unlock device on the medication cart. Staff #2 was observed to remove the keys and place them in her possession. The record for staff # 2 does not contain a license provided by the Commonwealth of Virginia to administer medications or a license as a medication aide with the Virginia Board of Nursing. 3. Staff #2 informed the inspector, the staff person responsible for medication administration was not onsite at the facility during this observation.
Based on the record review the facility failed to ensure the Individualized Service Plan ( ISP
Based on the record review the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff # 2, contains documentation of a TB risk assessment completed 02/05/22. There is no documentation of an annual TB risk assessment completed after 02/05/22.
Based on the record review the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: 1. The facility?s last practice of plan for resident emergencies is dated 08/14/22. The facility did not provide evidence of a practice of plan for resident emergencies being completed six months after 08/14/22.
Based on the record review the facility failed to ensure the ISP
Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff #2, hire date 08/17/2022, contains a criminal history record report dated 10/24/22. 2. The record for staff #1, hire date 08/13/21, contains a criminal history record report dated 11/12/21.
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on April 5, 2020 and concluded on April 7, 2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 20. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 6 staff records, activities, staff schedules, menus, health and fire inspections, healthcare oversight, pharmacy oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Based on record review and discussion, the facility failed to ensure the licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least every six months. Evidence: 1. The most recent Healthcare oversight only documented a review period of March 2021 and did not indicate a six-month period was completed since last review. 2. Staff #1 confirmed during discussion the healthcare professional did not provide oversight at least every six months.
Based on record review and discussion, the facility failed to ensure physician orders identified the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1?s physician?s orders dated 03-24-2021 did not document the diagnosis, condition, or specific indications for Amitriptyline or Tamsulosin. 2. Resident #2?s physician?s orders dated 03-24-2021 did not document the diagnosis, condition, or specific indications for blood sugar checks or Tamsulosin. 3. Staff #1 confirmed Resident #1 and Resident #2?s physician?s orders did not identify the required information.
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