Living Well Assisted Living

Based on record review, the facility did not 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. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: 1. The record for Resident #3 did not contain the signed Rights and Responsibilities for 2025 (last 1/31/24) in the resident?s record during inspection on 3/28/25. 2. Staff #2 confirms the Rights and Responsibilities was not present in the Resident?s record during inspection on 3/28/25.

Based on record review, the facility did not ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard. Evidence: 1.The physical examination for Resident #3 (completed 01/31/2024) was missing page 2 which reviews if Resident #3 has any of the conditions or care needs prohibited by 22VAC40-73-310 H. 2. Staff #2 confirms page 2 of the ISP

Based upon review of the UAI

Based on a review of two resident records, the facility did not ensure to regularly observe each resident for changes in physical, mental, emotional, and social functioning. The facility shall provide appropriate assistance when observation reveals unmet needs. 1. The record for resident #2 contained information identifying Heartland Home Hospice as the hospice provider, however there was no plan of care for the resident at admission. 2. The record for resident #2 identified the resident as a falls risk, however the plan did not contain falls risk. 3. The record for resident #2 identified the residents need for oxygen therapy, however the plan did not contain an outcome for oxygen therapy. 4. Staff #1 reviewed the records for Resident #2, acknowledged the residents record did not contain a hospice care plan. 5. Staff #1 reviewed the records for Resident #2, acknowledged the residents record did not contain falls risk. 6. Staff #1 reviewed the records for Resident #2, acknowledged the residents record did not contain an outcome related to oxygen therapy.

Based on a review of two resident records, it was determined that the facility did not ensure Upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. 1. The record for Resident #2 did not contain an orientation form with signatures from the resident or their legal representative. 2. Staff #1 reviewed the record for resident #2 and acknowledged the absence of the orientation form with signatures.

Based on a review of two resident records, it was determined the facility did not ensure the UAI

Based on record review, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight within compliance to the standard. Evidence: 1. There was not a health care oversight completed from 02/08/2023 to 01/19/2024.

Based on observation, the facility failed to ensure the current month's schedule of activities include the type and hour of the activity. Evidence: 1. During the tour of the facility on 03/19/2024, the current month?s activity calendar posted did not include the type and hour of the activity.

Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. Staff #2 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.

Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration keep the keys to the storage area on their person. Evidence: 1. During a tour of the facility on 03/19/2024, the medication cart was observed to be unattended with the keys noted in the cart and not on the individual responsible for medication administration.

Based on record review, observation, and interview, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it be prepared and served according to the physician's or other prescriber's orders. Evidence: 1. Resident #1 admitted to the facility on 12/21/2023 with an order for a puree diet with nectar thickened liquids; however, the order is not reflected in the resident?s record. 2. The resident was not served food pureed at lunch while onsite on 03/19/2024. 3. Staff confirmed there were no residents with a special diet.

Based on record review and interview, the facility failed to ensure for each resident assessed for assisted living care, except for those who self- administer all of their medications, a licensed health care professional, practicing within the scope of his profession, perform a review every six months of all the medications of the resident. Evidence: 1. Staff #1 confirmed the last medication review was conducted on 08/17/2023.

Based on interview, the facility failed to ensure medication aides are supervised by one of the following individuals listed in the standard. Evidence: 1. Staff #1 confirmed the facility does not currently employ a qualified individual to supervise medication aides.

Based on record review, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist. Evidence: 1. There was not a dietary oversight completed from 03/29/2023 to 11/01/2023.

Based on record review and interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. There was no documentation of a fire and emergency evacuation drill conducted from 05/31/2023-1/25/2024.

Based on record review, the facility failed to ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard. Evidence: 1. The physical examination for Resident #2 (completed 01/31/2024) was missing page 2 which reviews if Resident #2 has any of the conditions or care needs prohibited by 22VAC40-73-310 H.

Based on record review, the facility failed to ensure a criminal history record report issued by the State Police shall not be accepted by the facility if the report is dated more than 90 days prior to the date of employment. Evidence: 1. Staff #3 was hired on 02/01/2024; however, the criminal history record report for Staff #3 was completed 08/28/2023.

Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. Staff #1 was unable to provide documentation of the monthly checks of the first aid kit from June 2023-January 2024.

Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI

Based on observation, the facility failed to ensure that only oxygen from a portable source be used by residents when they are outside their rooms. The use of long plastic tether lines to the source of oxygen outside their rooms is not permitted. Evidence: 1. During a tour of the facility, Resident #1 was noted in a common dining area with an oxygen concentrator with a long plastic tether line.

Based on interview, the facility failed to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs. Evidence: 1. As of 12/13/2023, the facility has not employed a new administrator or appointed a qualified acting administrator causing a lapse in administrator coverage.

Based on observation and discussion, the facility failed to ensure doors leading to the outside not be locked from the inside or secured from the inside in any manner that amounts to a lock. Evidence: 1. Based on observation and discussion with Staff #1, all facility doors are secured upon entering and exiting the facility and only accessible via an access card.

Based on record review, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. On 12/18/2023, Resident #1 wheeled themselves out of the front door and fell. The resident sustained a bruise and contusion to forehead with 5 stitches. 2. Staff #2 was the designated person in charge at the time of the incident. 3. Staff #3 reported Staff #2 was ?inattentive? to the resident.

Based on record review, the facility failed to ensure the fall risk rating be reviewed and updated at least annually, when the condition of the resident changes, and after a fall. Evidence: 1. Resident #1 meets the criteria for assisted living care and fell on 12/18/2023. The last fall risk rating completed for Resident #1 was 12/5/2022.

Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency containing information listed in the standard. Evidence: 1. Staff #4, Staff #5, and Staff #6 did not have a statement verifying that the criminal history record report by the Virginia State Police has been obtained within 30 days of employment, is on file at the temporary agency, and does not contain barrier crimes.

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident #2?s blood pressure check order reads the following: ?check blood pressure while seated 3 times daily with meals for monitoring. If Blood Pressure <105/70, see as needed Midodrine Order.? Upon review of the June 2023 MAR

Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The June 2023 MAR

Based on record review and interview, the facility failed to ensure criminal history record reports be kept confidential. Reports on employees shall only be received by the facility administrator, licensee, board president, or their designee. Evidence: 1. The records of Staff #3 and Staff #4 indicate the criminal history record reports were not completed by the facility administrator or licensee. 2. Staff #1 acknowledged the criminal history record reports were completed by a separate organization/entity that is not owned nor operated by the facility.

Based on record review, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. During a review of Resident #2?s record, it was noted that on 2/1/23 Resident #2 fell out of bed, sustained a laceration to the back of the head, and was sent to the ER. The resident received stitches to the back of the head and returned to the facility. The assigned licensing inspector did not receive a notification of the incident.

Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. Staff #3?s record does not include verification that the staff person has received a copy of their current job description.

Based on observation and interview, the facility failed to ensure ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment, these materials or objects be inaccessible to the resident except under staff supervision. Evidence: 1. During the onsite inspection, shelves were noted outside the kitchen area in a resident hallway and contained a jug of vegetable oil and the staff member?s personal belongings (purse, water bottle, lunch, etc.). 2. Staff #1 and Staff #2 acknowledged the potential of these ordinary materials or objects may be harmful to a resident with a serious cognitive impairment and were accessible to residents without staff supervision.

Based on record review and discussion, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1 admitted on 3/21/23, and their admitting physician orders (11 total) did not identify the diagnosis, condition, or specific indications for administering each drug.

Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency contain information listed in the standard. Evidence: 1. The records of Staff #6 and Staff #7 indicate the background checks are not completed by the Virginia State Police.

Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration keep the keys to the storage area on their person. Evidence: 1. During a tour of the facility, the medication cart was observed to be unlocked and unattended with the keys noted on the cart and not on the individual responsible for medication administration.

Based on interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. During the onsite inspection, Staff #1, Staff #5, and Staff #6 were unable to provide a method of written communication as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.

Based on record review, the facility failed to ensure a current picture of each resident be readily available for identification purposes or, if the resident refuses to consent to a picture, there be a narrative physical description, which is annually updated, maintained in his file. Evidence: 1. Resident #1?s record did not include a current picture or a narrative physical description in their resident record.

Based on observation, record review, and interview, the facility failed to implement their written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. While ensuring accurate counts of all controlled substances with Staff #6, it was discovered that the count indicated on the Controlled Drug Record was not consistent with the amount of medication for Resident #3?s Lorazepam .5 mg tablets with 11 noted on the record as available with 10 tablets on the medication cart and Resident #4?s Gabapentin 100 mg capsule with 47 noted on the record as available with 46 capsules on the medication cart. 2. Staff #1 and Staff #6 acknowledged the Controlled Drug Record was not consistent with the amount of two medications identified on the medication cart.

Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI

Based on record review, the facility failed to ensure health information required by these standards be maintained at the facility and be included in the staff record for each staff person, and shall be maintained at the facility for each household member who comes in contact with residents. Evidence: 1. Staff #1 was unable to provide the results of a TB risk assessment for Staff #6.

Based on record review, the facility failed to ensure within four months of the starting date of employment, direct care staff 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. Evidence: 1. During the onsite inspection, Staff #1 and Staff #2 were unable to provide evidence of the required six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment and licensure (11/9/2023) for Staff #3 (hired 11/17/2022) and Staff #5 (hired prior to licensure).

Based on observation and discussion, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 03/23/2023, the signage of the manager on duty was blank and did not indicate the designated person in charge. Staff #4, Staff #5, and Staff #6 verbally stated Staff #6 was the designated person in charge; however, later Staff #1 stated Staff #4 was the designated person in charge at the time of the initiation of the inspection. 2. On 03/23/2023, Staff #1 acknowledged the current on-site person in charge was no posted in a place in the facility that is conspicuous to the residents and the public. 3. On the follow-up visit on 03/30/2023, the signage of the manager on duty was blank and did not indicate the designated person in charge.

Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #3 (hire date 11/17/22) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.

Based on record review and discussion, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. During the onsite inspection, Resident #1?s record did not contain a preliminary plan of care. 2. Staff #1 acknowledged Resident #1 (admitted 3/21/23) did not have a preliminary plan of care.

Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person. Evidence: 1. Staff #5?s record did not include written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year as the last review was completed on 12/23/2021.

Based on observation, the facility failed to ensure all resident records be kept in a locked area. Evidence: 1. Upon entry and during the tour of the facility, the area where resident records are stored was open, unlocked, unattended, and accessible.

Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission. Evidence: 1. During the onsite inspection, there was no evidence of written assurance for Resident #1 (admitted 3/21/2023) or their legal representatives documenting that the facility has the appropriate license to meet their care needs at the time of admission.

Based on record review and interview, the facility failed to ensure the MAR

Based on record review, the facility failed to ensure upon receiving licensure and admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. During the onsite inspection on 12/29/2022, Resident #1 (admitted 11/26/2022) and Resident #3 did not have evidence of receiving orientation.

Based on record review and observation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. On the admitting orders for Resident #1, there is an order for Flomax .4 mg tablet to be administered at night; however, the MAR

Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. During the onsite inspection on 12/29/2022, Resident #2 did not have a completed sex offender screening in their record.

Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs upon receiving licensure. Evidence: 1. During the onsite inspection on 12/29/2022, there was no evidence of written assurance to Resident #2, Resident #3 or their legal representatives documenting that the facility has the appropriate license to meet their care needs upon receiving licensure.

Based on record review, the facility failed to ensure the individualized service plan is signed and dated by the resident or their legal representative. Evidence: 1. During the onsite inspection on 12/29/2022, Staff #4 was unable to provide documentation indicating Resident #1, Resident #2, Resident #3, or Resident #4 have signed and dated their individualized service plan.

Based on record review and interview, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #4 admitted to the facility on 12/02/2022. A progress note dated 12/06/2022 indicates resident is diagnosed with advanced dementia, was physically aggressive with a family member, and admitted to an ALF due to the inability to manage the resident in the home setting. 2. During the onsite inspection on 12/29/2022, Staff #4 acknowledged Resident #4 did not have a mental health screen completed in their resident record.

Based on record review and discussion, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. Staff #5 was unable to provide the physician?s order for Mucinex Fast-Max DM Max Liquid as shown on Resident #4?s MAR

Based on record review and interview, the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative. Evidence: 1. During the onsite inspection on 12/29/2022, Resident #4 (admitted 12/02/2022) did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident record. 2. During the onsite inspection on 12/29/2022, Staff #4 acknowledged Resident #4 did not have written acknowledgement of receiving the facility?s disclosure statement in their resident record.

Based on observation, the facility failed to implement their written plan for medication management to include methods to prevent the use of outdated medications. Evidence: 1. A expired medication, Pantoprazole Sod DR 40 mg tablets expired 03/2022, for Resident #2 was observed in the medication cart for administration.

Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. 1. The December MAR

Based on staff record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of hire for each employee. Evidence: 1. The facility did not obtain a completed criminal history record reports for Staff #2 and Staff #6 (both hired 11/17/2022) on or prior to the 30th day of hire.

Based on observation, the facility failed to ensure common face/hand washing sinks have paper towels or an air dryer for hand washing. Evidence: 1. During the onsite inspection on 12/29/2022, the Licensing Inspector did not observe paper towels or an air dryer for hand washing in a hall bathroom used for resident use. The hall bathroom had a hand towel available for use.