Madonna Home INC.

Based on the report received from the facility, 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 # 1, admission date of 3/20/24 contained a Resident?s Rights document dated 3/24/24 during the onsite visit on 6/10/2025. The Resident Rights were not reviewed annually with the Resident. 2. Staff #1 confirms the Resident Right form was dated 3/20/24 during the onsite visit on 6/10/2025.

Based on the report received from the facility, the facility did not ensure that the resident has the right to voice or file grievances, or both, with the facility and to make recommendations for changes in the policies and services of the facility. The residents shall be protected by the licensee or administrator, or both, from any form of coercion, discrimination, threats, or reprisal for having voiced or filed such grievances. Evidence: 1. A complaint was received by the licensing inspector that the resident has expressed concerns about being afraid to voice concerns due to threats of being evicted. 2. During an interview with the resident, it was determined that the resident did not feel he could voice his concerns to the facility. 3. During an interview with Staff #1, it was determined that staff #1 did not address the residents concerns during the onsite visit on 6/10/2025.

Based on a review of six resident records, it was determined that the facility did not ensure the individualized service plan ( ISP

Based on a review of six resident records, it was determined the facility did not ensure the Individualized Service Plan ( ISP

Based on a review of six resident records, 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. 1. The record for resident #1 contained a review of Resident?s Rights dated 6/13/22 2. The record for resident #4 contained a review of Resident?s Rights dated 1/30/22 3. The record for resident #5 record contained a review of Resident?s Rights dated 6/15/22 4. Staff #4 reviewed the records for Resident #1, Resident #2 and resident #5 acknowledged the annual review of the residents? rights were not completed for those three residents.

Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. There is no sworn disclosure in Staff #2?s record.

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 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, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. The records of Resident #1, Resident #3, Resident #4, and Resident #5 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year. 2. The records of Staff #1, Staff #2, and Staff #3 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year.

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. The first aid kit was last checked on 04/13/2023.

Based on record review, 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 #2 admitted to the facility on 05/04/2023 and did not have a mental health screen completed in their resident record. The admitting UAI

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 July 2023 MAR

Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record. Evidence: 1. Staff #2?s record does not include verification that the staff person has received a copy of their current job description.

Based on record review, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment. Evidence: 1. The staff records of Staff #1 (hired 05/22/2023) and Staff #2 (hired 06/13/2023) do not include documentation of their staff orientation and initial training.

Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. There was not a completed criminal history record report for Staff #1 (hired 05/22/2023) and Staff #2 (hired 06/13/2023) in their record.

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #2 admitted to the facility on 05/04/2023. Resident #2?s admitting medication list included an order for Sertraline 100mg tablet to be administered one time daily and Lamotrigine 100mg tablet to be administered one time daily; however, these two medications were never placed on Resident #2?s MAR

Based on the onsite observation and discussion, the facility failed to ensure that the interior and exterior of all buildings shall be kept clean and free of rubbish. Evidence: During the tour of the physical plant , LI and LA observed a pile of broken free branches and a flat screen television located on the ground in the backyard of the facility.

Based on observation and record review, the facility failed to provide evidence of the rights and responsibilities review by resident annually. Evidence: The resident rights review dated for 1/30/22 for resident #5 was not signed.

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 in a place in the facility. Evidence: 1. During Inspection on 08/08/2022, Staff # 1 and Staff # 2 acknowledged the on-site person in charge was not posted.

Based on observation and discussion, during tour of the facility, the facility failed to ensure that residents always have cleaned sheets and pillowcases. Evidence: During the tour of the physical plant, LI and LA observed a pile of broken tree branches and a flat screen television located on the ground in the backyard of the facility.

Based upon staff record review and discussion, the facility failed to ensure that each staff person be evaluated annually and submit the results of a risk assessment, documenting that the individual is free of tuberculosis. Evidence: Staff #1 most recent tuberculosis is dated for 2-1-19.

Based on observation and discussion, the facility failed to store cleaning supplies and other hazardous materials in a looked area. Evidence: On August 8, 2022, during the tour of the facility, bleach and laundry detergent were found in the laundry room unlocked on the first floor.

Based on observation and staff interview , the facility failed to ensure that the administrator completed 20 hours of annual training. Evidence: Staff # 2 training record contained documentation of 11.25 hours of annual training.

Based on record review and discussion, the center failed to obtain an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before or no later than seven days after employment for each staff person. Evidence: 1. During staff record review, the following staff did not have a completed assessment for TB in a communicable form no earlier than 30 days before or no later than seven days after employment: 2. Staff #2 was hired on 2/5/2020. The assessment for TB was completed on 12/11/2019. 3. Staff #3 acknowledged the assessment for TB was not obtained earlier than 30 days before or no later than seven days after employment for Staff #2.

Based on record review and discussion, the facility failed to ensure the licensed health care professional identified the specific residents for whom the oversight was provided. Evidence: 1. Health Care Oversight dated 8/9/2020 to 2/11/2021, did not document the names of the residents for whom the oversight was provided. 2. Staff #3 acknowledged that the heath care oversight review did not identify the specific residents that were reviewed.

Based on record review and discussion, the facility failed to ensure all areas used by residents, including residents? bedrooms and common areas did not have a temperature that exceeded 80 degrees. Evidence: 1. While touring the facility, the upstairs hallway temperature thermostat registered at 81 degrees. 2. The outside temperature posted was 77 degrees. 3. Staff #1 confirmed that the upstairs hallway temperature thermostat registered at 81 degrees.