Mary Marshall Assisted Living Residence

Based on resident record review and staff interview, the facility failed to ensure that care provision and service delivery should be resident-centered to the maximum extent possible and include: prompt response by staff to resident needs as reasonable to the circumstances and preferences. Evidence: 1. On 12/01/2025, the facility provided a memo to all residents and staff providing information on impending construction to the bathrooms in resident 1, resident 2, resident 3, and resident 4?s units. 2. During the onsite inspection, 03/09/2026, staff 5 confirmed that the construction to the bathrooms in resident 1, resident 2, resident 3, and resident 4?s units were completed. 3. During the onsite inspection, 03/09/2026, staff 5 confirmed that construction to resident 1, resident 2, resident 3, and resident 4?s bathrooms began January 2026 and have been completed. 4. During the onsite inspection, 03/09/2026, licensing staff toured resident 3?s unit and noted that the bathroom was blocked off with construction tarp; however, it was accessible with the tarp cut open, and the toilet had a brown substance around the inside of the commode and appeared inoperable. LI and LA interviewed resident 3 who confirmed an inability to use the toilet or the shower for ?months?, and that the construction workers advised them not to enter the bathroom. 5. During the onsite inspection, 03/09/2026, licensing staff interviewed resident 4, who confirmed an inability to utilize the bathroom for ?a month or so.? Resident 4 stated that the shower was now in working condition; however, they were advised that the toilet could not be used. Resident 4 confirmed that staff were notified of an inability to use the toilet for the past ?couple of weeks.? LI and LA observed that resident 4?s toilet had duct tape wrapped from the lid to the bottom of the toilet. 6. During the onsite inspection 03/09/2026, staff 5 was unaware that the bathrooms of resident 3 and resident 4 were not completed as indicated. Staff 5 also acknowledged that the timeframe to complete the work given to the residents was not followed.

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

Based on observation and staff interview, the facility failed to ensure that all records are treated confidentiality and that information should be made available only when needed for care of the resident. All records should be made available for inspection by the department?s representative. Evidence: 1. During the onsite inspection, 03/09/2026, licensing inspector (LI), licensing administrator (LA), and staff 6 toured the facility. While in the dining room, LI observed a clipboard holding a resident list and those residents with special diets on the windowsill at the door of the dining room. Staff 6 was notified of the confidential information visible on the clipboard and removed the clipboard, placing it in an office. While LI and LA were walking away from the dining room, LI observed staff 7 returning the clipboard with resident names to the windowsill in the dining room. Staff 6 acknowledged observing staff 7 returning the confidential document(s) to the windowsill of the dining room. 2. During the onsite inspection, 03/09/2026, LI, LA, and staff 6 toured resident 3?s unit. LI and LA observed a memo on resident 3?s door, which indicated resident names and units that were on the list for construction to the bathrooms. Staff 6 acknowledged the confidential information and removed the posting from resident 3?s bathroom.

Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident. Evidence: 1. On 02/24/2026, licensing inspector (LI) received notification of a plumbing issue affecting 5 bathrooms and 4 residents. The incident report indicated that the redesigning of the bathrooms started in the beginning of January 2026 with an expected completion of March 2026. 2. During the onsite inspection, 03/20/2026, staff 5 acknowledged that the plumbing issue began with 1 bathroom in August 2025; additional bathrooms experienced plumbing issues November 2025, and the construction started January 2026. Staff 5 confirmed that an incident report was not submitted to licensing until after the renovations started in March 2026.

Based on staff record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities should 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 should be the resident?s, his legal representative?s or responsible individual?s or staff person?s written acknowledgment of having been so informed, which should include the date of the review and should be filed in the resident?s or staff person?s record. Evidence: 1. Staff 1 (hire date, 05/24/2023) completed a resident rights review on 06/10/2023. 2. During the onsite inspection, 03/09/2026, staff 5 acknowledged that staff 1?s record did not include an annual review of the rights and responsibilities of residents in assisted living facilities from 2024-2025.

Based on staff record review and staff interview, the facility failed to ensure that all direct care staff should attend at least 18 hours of training annually. Evidence: 1. Staff 1 was hired on 05/24/2023 and works as direct care staff. Staff 1?s records indicated that 2 hours of annual training was completed during January 2024 through December 2025. 2. During the onsite inspection, 03/09/2026, staff 5 confirmed that staff 1 did not attend at least 18 hours of training annually.

Based on record review and staff interview, the facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Evidence: 1. Upon request, the facility did not provide an annual review of the emergency preparedness plan. 2. During the onsite inspection, 09/30/2025, staff 5 confirmed that the emergency preparedness and response plan was not documented as reviewed annually by signing and dating.

Based on record review and staff interview, the facility failed to ensure that at least every six months, all staff currently on duty on each shift should participate in an exercise in which the procedures for resident emergencies were practiced. Documentation of each exercise was maintained in the facility for at least two years. Evidence: 1. Upon request, the facility did not provide documentation that at least every six months that all staff on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced. 2. During the onsite inspection, 09/30/2025, staff 5 confirmed that procedures for resident emergencies were not documented as practiced every six months with all staff on duty on each shift.

Based on record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section were reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person. Evidence: 1. Upon request, the facility did not provide documentation that the resident emergency plan was reviewed at least every six months with all staff. 2. During the onsite inspection, 09/30/2025 staff 5 confirmed that the plan for resident emergencies was not documented as reviewed at least every six months by signing and dating of each staff person.

Based on record review and staff interview, the facility failed to ensure that elevators were kept in good running condition and were inspected at least annually. The signed and dated certificate of inspection issued by the local authority should be evidenced of such inspection. Evidence: 1. Elevator 1?s certificate was signed and dated 01/14/2024. The certificate expired on 01/13/2025. 2. Elevator 3?s certificate was signed and dated 04/22/2021. The certificate expired on 03/28/2022. 3. During the onsite inspection on 09/30/2025, staff 5 confirmed that elevator 1?s certificate expired on 01/13/2025 and elevator 3?s certificate expired on 03/28/2022.

Based on record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, with emphasis placed on an individual?s respective responsibilities. The review should be documented by signing and dating. Evidence: 1. The emergency preparedness and response plan was reviewed with staff on 07/23/2025 and 08/14/2024. 2. During the onsite inspection, 09/30/2025 staff 5 confirmed that the emergency preparedness and response was not reviewed semi-annually with staff.

Based on staff record and staff interview, the facility failed to ensure that staff administering medications to residents should be registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. Staff 3?s (hire date, 09/18/2023) medication administration license was issued 03/23/2021 through Maryland Board of Nursing. 2. During the onsite inspection, 09/30/2025 staff 5 and staff 6 confirmed that staff 3?s medication administration license was issued through Maryland Board of Nursing.

Based on record review and staff interview, the facility failed to maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified needs for the residents in care. Evidence: 1. The staffing plan indicated that Licensed Practical Nurses (LPN) were to be scheduled seven days a week, 2:00 PM ? 10:30 PM; three Mental Health (MH) Team Leader were to be scheduled in staggered shifts seven days a week; and two Home Health Aides (HHA)/Medication Technicians (MT) were to be scheduled each shift for eight hours, three shifts a day, seven days a week. 2. During the onsite inspection, 09/30/2025, licensing inspector (LI) reviewed the LPN, MH, and HH/MT schedules and it was not consistent with the direct care staff titles or the schedule indicated in the staffing plan. 3. July 2025 and August 2025?s schedule indicated that there was one LPN scheduled per shift daily (three shifts per day); two MH?s (current title, Resident Service Manager) were scheduled 8:00 AM ? 4 PM daily; two HHA?s (current title, Resident Care Coordinator) were scheduled each shift (two shifts per day); and two MT?s were scheduled per shift (two shifts per day).

Based on record review and staff interview, the facility failed to provide a statement that the facility maintains liability insurance in force to compensate residents or other individuals for injuries and losses from the negligent acts of the facility. The statement should be made on the liability insurance statement provided by the department. Evidence: 1. Upon request, the facility did not provide the liability insurance statement on a form provided by the department. 2. During the onsite inspection, 09/30/2025, staff 5 confirmed that the liability statement was not provided on a form developed by the department.

Based on record review and staff interview, the facility failed to provide a disclosure statement on a form developed by the department. Evidence: 1. Upon request, the facility did not provide a disclosure statement on a form developed by the department. 2. During the onsite inspection, 09/30/2025, staff 5 confirmed that the disclosure statement was not provided on a form developed by the department.

Based on staff records and staff interview, the facility failed to ensure that a facility licensed for both residential and assisted living care, all direct care staff attended at least 18 hours of training annually. Evidence: 1. Staff 3 (hire date, 09/18/2023) training records indicated that they completed 3.25 hours of annual training from 01/01/2024 through 01/01/2025. The training log was signed by the executive director on 07/29/2025. 2. Staff 3?s training records also included a two-hour ?All Staff Meeting/Training NARCON Training? on 05/22/2024. 3. During the onsite inspection, 09/30/2025, staff 5 and 6 confirmed that staff 3?s training records indicated that they completed 5.25 hours of annual training.

Based on record review and staff interview, the facility failed to ensure to submit a written report of each incident to the regional licensing office within seven days from the date of the incident. Evidence: 1. On 11/22/2024, staff 1 submitted an initial incident report indicating that resident 1 was missing since 11/20/2024. Staff 1 did not submit a written report of the incident within seven days from the date of the incident. 2. The incident report submitted on 11/22/2024 did not include the name and address of the facility, location of the incident, actions to prevent recurrence of the incident, name of staff person in charge at the time of the incident, names, telephone numbers, and addresses of witnesses to the incident, and name, title, and signature of the person making the report. 3. On 11/25/2024, LI contacted staff 1 via email requesting an update. Staff 1 responded stating that resident 1 had ?not been found.?

Based on facility record review, the facility failed to submit to the regional licensing office amendments to the written report when circumstances require, such as when significant new information becomes available. Evidence: 1. Resident 1?s (admit date, 7/5/2017) progress note (1/7/2025) stated, ??resident 1 was picked up this morning and taken to jail. Staff 2 emailed caseworkers.? 2. The facility did not submit an amendment to the written report when resident 1 was located. 3. On 1/27/2025, LI interviewed staff 1 who confirmed that an amendment to the written report was not submitted to the licensing office.

Based on facility record review and staff interview, the facility failed to ensure that each facility reported to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of the resident. Evidence: 1. On 11/22/2024, staff 1 submitted an incident report indicating resident 1 was missing since 11/20/2024. This incident was not reported within 24 hours of occurrence. 2. On 01/27/2025, LI interviewed staff 1, confirmed that the missing resident notification was not reported within 24 hours of occurrence.

Based on resident record review and staff interview, the facility failed to ensure that upon receipt of recommendations noted by a dietitian or nutritionist; the administrator dietician, or nutritionist shall report them to the resident?s physician. Documentation of the report shall be maintained in the resident?s record. Evidence: 1. Resident 1?s dietician report (completed 03/24/2024) states a calorie-controlled diet and thin liquid diet. 2. No documentation was present in Resident 1?s record regarding action taken to recommendation in dietician report. 3. On 06/17/2024, LI interviewed Staff 4 confirmed that the documentation was not present in Resident 1?s record.

Based on facility record review and staff interview, the facility failed to ensure that the fire and emergency evacuation drill frequency and participation were in accordance with the current edition of the Virginia Statewide Fire Prevention Code. Evidence: 1. A fire drill was not conducted in the month of May 2024. 2. On 06/17/2024, LI interviewed Staff 6 confirmed that a fire drill was not conducted in May.

Based on LI observation and staff interview, 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. On 06/17/2024, LI observed boxes stacked against the hallway of the second floor. 2. On 06/17/2024, during a facility tour, Staff 5 confirmed that boxes were stacked in the hallway. 3. On 06/17/2024, LI observed a fan against the wall with an unsecured plug laying in the middle of the lobby floor.

Based on resident record review and staff interview, it was determined that medications for Res C and D were not administered in accordance with the physician's orders. Evidence: The Medication Administration Record ( MAR

Medications are required to be locked and can only be kept in a residents room, if the doctor signs an order stating the resident is able to administer own medications. Resident #2 is assessed as needing help with medication. Tums and eye drops were found in room.

Health Care Oversight is required to be signed by a licensed Health Care professional. The most recent Health Care Oversight dated 7/11/22 was signed by the Administrator, however this does not meet the Standard as Administrator is not a licensed Health Care professional.