Poet's Walk Leesburg

Based on staff record review and staff interview, the facility failed to ensure the sworn statement or affirmation was completed by all applicants for employment. Evidence: 1. The LI requested a list of employees with hire dates. The employee list contained approximately 32 individuals with hire dates prior to the change of ownership that occurred on 08/13/2025. 2. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 1 and 5 confirmed that the staff hired before 08/13/2025 had not completed sworn statements or affirmations as required due to the Change in Ownership.

Based on direct observation and staff interview, the facility failed to ensure menus, including substitutions or additions, were dated and posted for the current week in an area conspicuous to residents. Evidence: 1. On 01/06/2026 and 01/09/2026, the LI did not observe a posted menu including substitutions. 2. On 01/06/2026, Staff 8 provided a copy of the menu. The menu stated the breakfast was pancakes. The LI observed breakfast as waffles. There were no substitutions listed on the menu. 3. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the menu was not posted.

Based on direct observation and staff interview, the facility failed to ensure a procedure for pasting the name of the current on-site person in charge in the facility that is conspicuous to the residents and the public was developed and implemented. Evidence: 1. Upon arrival on 01/09/2026, the LI observed the posted Manager on Duty as Staff 8; however, Staff 10 stated that they were current person in charge. 2. In an interview with the LI on 01/09/2026, Staff 2, Staff 10, and Staff 8 confirmed that Staff 8 was not in the building and/or the current on site person in charge.

Based on direct observation, resident record review, and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers? instructions and consistent with the standards of practice approved by the Virginia Board of Nursing. Evidence: 1. Resident 4?s Medication Review Report, signed 12/15/2025, contains the following orders: a. Aspirin Low CHW 81 MG: Chew and Swallow 1 tablet by mouth every morning b. Acetamin Tab 500 MG: Take 2 tablets by mouth twice daily c. Buspirone Tab 7.5 MG: Take 1 tablet by mouth three times daily d. Famotidine Tab 20 MG: Take 1 tablet by mouth twice daily e. Memantine Tab HCL 5MG: Take 1 tablet by mouth twice daily f. Calcium+D3 Tab 315-250: Take 1 tablet by mouth twice daily 2. On 01/09/2026, the LI observed Staff 10 crush the following medications prior to administering: Aspirin, Acetamin, Buspirone, Famotidine, Memantine, and Calcium. 3. Resident 4?s record does not contain an order to crush medication. 4. In an interview with the LI on 01/09/2026, Staff 10 stated that they did not know where to review if Resident 4 had a crush order. Staff 8 confirmed medication was not administered per physician orders.

Based on resident record review, staff record review and staff interview, the facility failed to ensure that records, reports, plans, schedules and other information was kept and maintained as required by this chapter. Evidence: 1. The LI requested a list of employees with hire dates. The employee list contained approximately 32 individuals with hire dates prior to the change of ownership that occurred on 08/13/2025. 2. During a review of Staff 5?s files on 01/06/2025, the LI observed that Staff 5, hired on 02/03/2025, the LI observed that Staff 5?s record was not brought current to reflect the Change of Ownership that occurred in August of 2025. Staff 5?s record contained an orientation, sworn statement or affirmation, criminal record report, and job description completed in or around February of 2025 at the time of hire. 3. The LI requested a list of residents with admission dates. The resident list contained approximately 35 residents with admission dates prior to the change of ownership that occurred on 08/13/2025. 4. During a review of Resident 2, Resident 3, Resident 4, and Resident 5?s files on 01/06/2025, the LI observed Resident 2 (Admitted 12/15/2023), Resident 3 (Admitted 02/25/2025), Resident 4 (Admitted 11/11/2021), and Resident 5 (Admitted 04/01/2025), were not brought current to reflect the Change of Ownership that occurred in August of 2025. Records for Resident 2, Resident 3, Resident 4, and Resident 5 contained agreements, disclosure forms, written assurance, and interviews dated at time of noted admissions. 5. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 1 and 5 confirmed that the staff and resident records for those hired or admitted prior to 08/13/2025 had not been maintained as required with the Change of Ownership.

Based on direct observation, resident record review, and staff interview, the facility failed to ensure medication was administered no earlier than one hour before and not later than one hour after the facility's standard dosing schedule. Evidence: 1. Resident 19?s Medication Review Report, signed 12/23/2025, contains the following orders: a. CoQ10 Cap 200 MG: Take one capsule by mouth once daily b. Enalapril Tab 10 MG: Take 2 tablets by mouth every morning c. Fluoxetine Cap 10 MG: Take 1 capsule by mouth every morning d. Magnesium Tab 250MG: Take 1 tablet daily by mouth e. Selenium Cap 200 MCG: Take 1 capsule by mouth once daily f. Vitamin B-12 Tab 1000MCG: Take 1 tablet by mouth once daily 2. During a medication pass for Resident 19, the LI observed Staff 10 administer the following medications approximately 2 hours after they were due at 8:00 AM: Coq10, Enalapril, Fluoxetine, Magnesium, Selenium, Vitamin B012. 3. Resident 19?s Medication Admin report shows that the medications listed above were administered at 10:20 AM. 4. In an interview with the LI on 01/09/2026, Staff 8 confirmed that medication was administered more than one hour after the schedule administration time.

Based on facility document review, direct observation, and staff interview, the facility failed to ensure an infection control program was developed, in writing, implemented, and addressed surveillance, prevention, and control of disease and prevention consistent with the CDC and OSHA regulations. Evidence: 1. Upon arrival to the facility on 01/09/2026, the LI was let into the safe, secure unit by Staff 10. Staff 10 walked the LI from the front of the building to the medication carts. Staff 10 did not wash their hands or apply hand sanitizer and put on gloves to begin passing medication. The same gloves remained on Staff 10?s hands from the first medication pass to the third medication pass, including time for documentation and walking to resident rooms to ascertain the location of residents not in the dining area. 2. The facility?s Infection Control Program states the following on page 08 under Hand Hygiene: ?All individuals must adhere to strict hand hygiene practices, including washing hands frequently with soap and water for at least 20 seconds or using alcohol-based hand sanitizers when soap and water are not available.? 3. In an interview with the LI on 01/09/2026, Staff 8 confirmed the infection control program was not implemented relating hand hygiene.

Based on resident record review and staff interview, the facility failed to ensure that all residents and applicants were assessed face to face using the UAI

Based on staff record review and staff interview, the facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee. Evidence: 1. The LI requested a list of employees with hire dates. The employee list contained approximately 32 individuals with hire dates prior to the change of ownership that occurred on 08/13/2025. 2. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 1 and 5 confirmed that the staff hired before 08/13/2025 had not completed criminal history record reports as required due to the Change in Ownership.

Based on staff record review and staff interviews, the facility failed to ensure direct care staff met one of the requirements upon hire or within two months of employment. Evidence: 1. Staff 5?s (hired as direct care staff on 02/03/2025) and Staff 6?s (hired as direct care staff on 10/17/2025) records did not include documentation of having met one of the requirements of direct care staff upon hire or within two months of employment. 2. In an interview with the LI on 01/09/2026, Staff 8 confirmed that Staff 5 and Staff 6?s qualifications did not meet the requirements.

Based on facility document review and staff interview, the facility failed to ensure a written staffing plan was maintained that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs. Evidence: 1. The LI requested a copy of the written staffing plan in writing to Staff 2 and Staff 8 on 01/09/2026. 2. The written staffing plan was not provided for review on 01/09/2026 during the inspection.

Based on direct observation and staff interview, the facility failed to ensure there was staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. Evidence: 1. On 01/09/2026, the LI arrived at the facility and observed three (3) direct care staff alongside one (1) registered medication aide serving breakfast, getting residents out of bed, and administering medication (RMA only). 2. In an interview with the LI, Staff 10 stated that they had a call out and had to work two carts to cover for the other individual. 3. The LI requested a copy of the schedule, including the actual worked shifts, for 01/09/2026. The facility provided a schedule for 01/09/2026, that included one certified medication tech from 7:00 AM to 3:00 PM and four caregivers from 7:00 AM to 3:00 PM. 4. In an interview with the LI on 01/09/2026, Staff 8 confirmed that there were not enough staff to adequately meet resident needs on 01/09/2026.

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

Based on facility document review and staff interview, the facility failed to ensure liability insurance coverage was maintained according to the capacity tiers. Evidence: 1. On 01/06/2026, Staff 1 provided a copy of the liability insurance dated to expire on 04/15/2026. The insurance provided did not list the current licensee as insured. 2. In an interview with the LI on 01/06/2025, Staff 1 stated that it might not be the correct copy and they would attempt to locate the current liability insurance. 3. On 01/09/2026, LI provided an opportunity to upload the document via a shared folder during the on-site inspection. The document was not uploaded for review at the time of inspection.

Based on direct observation, resident record review and staff interview, the facility failed to ensure resident records were kept current, retained at the facility, and kept in a locked area. Evidence: 1. Upon the LI?s arrival at the facility on 01/09/2026, Staff 10 stepped away from the medication carts to allow the LI access to the safe, secure unit. When arriving back to the medication carts, the LI observed the computer open to Resident 6?s electronic medication administration record. 2. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the resident records were not kept current, and Resident 6?s record was left open to access.

Based on staff record review and staff interview, the facility failed to ensure direct care staff attended at least 10 hours training in cognitive impairment within four months of the starting date of employment in the safe, secure unit. Evidence: 1. Staff 5, hired on 02/03/2025, was a direct care staff member that works in the safe, secure unit. Staff 5?s record contained .75 hours of cognitive impairment training completed since 02/03/2025. 2. In an interview with the LI on 01/09/2026, Staff 8 confirmed that Staff 5 did not attend at least 10 hours of training in cognitive impairment within 4 months of their starting date of employment, 06/03/2025, in the safe, secure unit.

Based on direct observation and staff interview, the facility failed to ensure the following items were posted on the premises: the most recently issued license, the most recent inspection findings, and any other documents required by the commissioner. Evidence: 1. On 01/06/2026 and 01/09/2026, the LI did not observe the license posted in an area conspicuous to the public. 2. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 8 confirmed that the license was not posted.

Based on direct observation and staff interview, the facility failed to ensure freedom of movement was provided for the residents to common areas and to their personal spaces. The facility may not lock residents out of or inside their rooms. Evidence: 1. While walking back to the medication cart after a medication pass observation on 01/09/2026, the LI overheard Resident 6 state ?I?m locked out.? 2. In an interview with the LI on 01/09/2026, Resident 6 stated that the door was locked, and they couldn?t get in. The LI attempted to open the locked door with Resident 6 present. The LI got the attention of Staff 11 to open the door for Resident 6. 3. During the inspection on 01/09/2026, the LI observed 27 resident rooms locked while residents were out of the building. 4. In an interview with the LI, Staff 10 stated that the doors remain locked to ensure residents don?t enter other resident rooms.

Based on direct observation and staff interview, the facility failed to ensure the written schedule of activities was developed monthly, included required information and substitutions, and was posted in a conspicuous place or otherwise available to residents and their families. Evidence: 1. On 01/06/2026 and 01/09/2026, the LI did not observe a posted activity calendar. 2. In an interview with the LI on 01/06/2026, Staff 8 stated that the January calendar was not complete due to the change in activity director. Staff 8 stated they were still using the December calendar which was posted on the back of resident doors and provided to resident families digitally. Staff 8 confirmed that resident families receive it digitally, but most residents do not. 3. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the activity calendar was not provided to residents or posted.

Based on direct observation and staff interview, the facility failed to ensure that ordinary materials or objects were inaccessible to residents when there were indications that they may be harmful to a resident. Evidence: 1. Upon the LI?s arrival at the facility on 01/09/2026, Staff 10 stepped away from the medication carts to allow the LI access to the safe, secure unit. 2. When walking back to the medication carts, the LI observed that both carts were parked to the left of the entrance to the dining area where residents were having breakfast. The LI observed both carts containing a basket with various supplies, including hand sanitizer, on the top of the cart. The cart to the right, identified as the cart for the 300-400 hallway, also contained wipes. 3. During the observed medication pass, Staff 10 was gathering medication out of the cart to the left, identified as the cart for the 100-200 hallway. At the same time, Resident 20 went to the cart and began to grab the wipes. Resident 20 picked up the wipes, opened the container, and began to pull the wipes out of the container. Neither the staff in the adjacent dining area nor Staff 10 responded until the LI got the attention of Staff 10 to remove the cleaning wipes.

Based on facility document review and staff interview, the facility failed to ensure an orientation and semiannual review of the emergency preparedness and response plan was developed, implemented, and documented by signing and dating for all staff, residents and volunteers. Evidence: 1. The LI requested a copy of the emergency preparedness orientation or semi-annual review with staff and residents on 01/06/2026 and 01/09/2026. 2. The facility was provided with an opportunity to submit the plan for review via shared folder online on 01/09/2026. In an interview with the LI on 01/09/2026, Staff 2 stated they would locate the information and submit it. 3. The emergency preparedness plan orientation or semi-annual review was not submitted for review during the course of the inspection on 01/06/2026 and 01/09/2026.

Based on facility document review and staff interview, the facility failed to ensure volunteers attended an orientation prior to beginning volunteer service and signed and dated a statement that they received and understood orientation information. Evidence: 1. The LI requested the volunteer records for any active volunteers on 01/06/2026. Staff 8 provided one active volunteer, Collateral Contact 1. 2. Collateral Contact 1?s record did not contain a statement that they received and understood orientation information.

Based on direct observation, resident record review, and staff interview, the facility failed to ensure all medications administrations to residents were documented on the medication administration record ( MAR

Based on facility document review, resident record review, direct observation, and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components. Evidence: 1. On page seven (7) of the facility?s medication management plan, it states ?Staff must begin by washing their hands and assembling the equipment necessary for administration.? 2. On 01/09/2026, the LI observed Staff 10 pass medications with the same gloves on, not washing their hands, for three residents. 3. On 01/09/2026, the LI observed Staff 10 drop a pill on the floor while preparing medication to be passed. The pill was then thrown into the open trash can on the side of the cart. 4. The facility?s medication management plan does not cover disposal of non-narcotic medication. 5. On page 1 of the Resident Medication Administration policy, it sates ?Medications are to be prepared, administered, and documented by qualified staff members per your state guidelines.? 6. On 01/09/2026, the LI observed Staff 10 document the medication pass for 13 residents that were not observed by the LI. Staff 10 stated that the medication had been passed earlier but there was not enough time to document. 7. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the medication management plan had not been implemented.

Based on staff record review, resident record review, and staff interview, the facility failed to ensure staff responsible for medication administration were licensed by the Commonwealth of Virginia to administer medications or registered with the VA Board of Nursing as a medication aide. Evidence: 1. During a tour of the facility on 01/06/2026, the LI observed that Staff 9 was working the cart. 2. In an interview with the LI on 01/06/2026, Staff 8 stated that Staff 9 would be passing medications during the medication pass observation. 3. After a review of the license lookup tool provided by DH online, Staff 9?s license as a Registered Medication Aide expired on 11/30/2025. Staff 8 stated that Staff 9 had been passing medications all morning to all residents with scheduled medication and pulled Staff 9 off the cart. 4. On 01/06/2026, Staff 8 provided a Medication Admin Audit Report for Staff 9 to show all passes completed by Staff 9 between 12/01/2025 and 01/06/2026. The document contains 454 pages of medication administration records for multiple residents. The report indicates that medication was passed for 33 residents on 01/06/2026, and approximately 4,700 doses were passed to 45 residents total from 12/01/2025 to 01/06/2025. 5. On 01/06/2026, Staff 2 provided a schedule containing the dates worked by Staff 9 between 11/30/2025 and 01/06/2026. Staff 9 was scheduled on the following dates on various shifts: November 30th, 2025 through December 04th, 2025, December 06th through December 07th, 2025, December 09th, 2025 through December 12th, 2025, December 15th, 2025 through December 18th, 2025, December 20th, 2025 through December 21st, 2025, December 23rd, 2025 through December 25th, 2025, December 29th, 2025, January 03rd, 2025 through January 24th, 2025 and January 06th, 2025. 6. In an interview with the LI on 01/09/2026, Staff 8 confirmed that Staff 9?s license to practice as a registered medication aide was expired from 11/30/2025.

Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy-issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. On 10/07/2025, at approximately 12:38 p.m., the Licensing Inspector (Ll) audited the medication cart and observed that the prescription medication BREO Ellipta inhalation powder inhaler was not contained in a box with identifiable resident information. 2. Staff 4 conformed the inhaler was not in a prescription box and belonged to resident 6. 3. Photo evidence taken.

Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area. Evidence: 1. On 10/07/2025, at approximately 10:08 a.m., the Licensing Inspector (LI) observed that resident 4's bathroom in the memory care facility contained one bottle of Listerine mouthwash, one spray bottle of Downy Wrinkle Releaser, two cans of Lysol disinfecting spray, and two bottles of body lotion, all stored in an unlocked area. Resident 4 also had a desk in the bedroom with a cup containing two pairs of scissors, which was also in an unlocked area. 2. At approximately 12:29 p.m., the Licensing Inspector (LI) observed one white glass bottle of Old Spice aftershave, one bottle of Adidas aftershave, and one green disposable razor stored in an unlocked cabinet in resident 5's bathroom within the memory care facility. 3. Photo evidence taken.

Based on observations made during a tour of the building, the facility failed to ensure the interior of the building shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1. The Licensing Inspector (LI) observed the following during the facility tour: a. A set of blinds in resident 5 's room were torn and broken, held together at one end with a rubber band. 2. In the Blue Ridge Cafe: a. A brown wall divider had three veneer squares intact, while the fourth square was missing. Glue residue was visible where the missing square had once been. b. A set of wooden blinds had a broken area. c. The paint on the walls was scratched and marked in the dining area. 3. The main kitchen door was stained and marked with scrapes and yellow discoloration. 4. The door to Room 215 had large black scratches across the middle. 5. The carpet in front of room 208 had a long white stain. 6. The main door near the salon had black scrapes and areas where paint had been scraped off the middle section. 7. Photo evidence taken.

Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident 1 had an admission date of 07/14/2025 and the resident's record did not contain a Sex Offender Screening. 2. Resident 2 had an admission date of 09/15/2025 and the resident's record did not contain a Sex Offender Screening. 3. Resident 4 had an admission date of 08/31/2024 and the resident's record did not contain a Sex Offender Screening 4. During an interview with Staff 1 and Staff 2, they were unable to locate the sex off ender screenings at the time of the inspection.

Based on record review and staff interview, the facility failed to administer medication in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Upon record review during the onsite inspection on 10/07/2025, Resident 1 has a physician order dated 02/26/2025, Rivastigmine Dis 9.5 mg, apply a new patch to the skin once daily every morning. 2. In an interview with the LI, staff 2 confirmed that resident 1 arrived at the hospital on 10/02/2025 wearing two Rivastigmine 9.5 mg patches.

Based on documentation and interview, the facility failed to implement their written plan for medication management. Evidence: 1. On 10/03/2025, the Licensing Inspector (LI) received an APS report stating that resident 1 arrived at INOVA Hospital on 10/02/2025 with two Exelon (Rivastigmine 9.5 mg) patches on their arm, neither of which had a written indication of the date or time. 2. Resident 1?s October Electronic Administration Record (eMAR) was reviewed during the inspection. Resident 1?s e- MAR