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Public Google reviewers rate this highly and often mention compassionate and attentive nursing staff. Schedule a visit to confirm the fit.
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Public Google reviewers rate Sunrise at Bluemont Park highly. Reviewers highlight: compassionate and attentive nursing staff, beautiful, well-maintained grounds and location. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Families generally praise the facility for its compassionate, person-centered staff and beautiful, park-like grounds. While many long-term residents thrive here, recent reviews highlight a critical concern regarding a long-term broken elevator in the Potomac building and issues with food presentation.
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Key Review Excerpts
“The staff that takes care of my mother is kind and really treat her on a holistic manner. They take the time to connect with her and really know her .”
“The staff at Sunrise Bluemont is top notch! I heartily recommend this facility for respite or long-term care for family or loved ones.”
“Six months into the Bluemont experience, we feel we made the right decision. Supported by a loving staff, she has made the transition and sees Bluemont as her home.”
Source: VA State Licensing Agency
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/18/2026 Time in: 12:13 PM Time out: 1:40 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-reported incident) was received by VDSS Division of Licensing on 03/03/2026 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 155 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: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities. Additional Comments/Discussion: The evidence gathered during the investigation did not support the allegation(s) 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2026 Time in: 11:19 AM Time out: 12:49 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/18/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, Buildings and Ground, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 157 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents sitting in common areas interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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
Based on resident and staff interviews, the facility failed to make care provision and service delivery should be resident-centered to the maximum extent possible and include resident participation in decisions regarding the care and services provided to him; personalization of care and services tailored to the resident?s circumstances and preferences; and prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. During the onsite inspection, 01/23/2026, licensing inspector (LI) interviewed collateral contact 1 who stated, ?I have not seen anyone use the electric evac chairs. I didn?t know that we had those, but I think that people are afraid to use the stairs. They don?t want to fall.? 2. During the onsite inspection, 01/23/2026, LI interviewed collateral contact 2 who stated, ?I think it stinks. I live on the terrace level ? people on higher levels are missing relationships with others. People have to move out.? LI asked collateral contact 2 if they used the evac chair to visit their friend(s). Collateral contact 2 stated that they were unaware of the option and ?did not know? about the evac chair. 3. During the onsite inspection, 01/23/2026, staff 1 confirmed that the residents were not formally informed that evac chairs were available for use. Staff 1 stated that legal representatives, family members, residents with email addresses, and power of attorneys (POA?s) were advised via email but could not be sure if that information was passed along to the residents.
Based on record review and staff interview, the facility failed to ensure that elevators, where used, should be kept in good running condition and should be inspected at least annually. Evidence: 1. Potomac building?s elevator has not been functioning, 12/03/2025 to present. There are over forty residents that reside in the Potomac building. 2. During the onsite inspection, 01/23/2026, staff 1 confirmed that Potomac building?s elevator was not online, 12/03/2025 to present. Staff 1 stated that the elevator requires a ?jack,? that must be manufactured, which takes about six to eight weeks. Staff 1 confirmed that the elevator should be in working order by mid- March 2026.
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: 07/18/2025 Time in: 10:40 AM Time out: 4:19 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: 143 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents waiting for transportation services, dining for lunch, and engaging in scheduled activities. Additional Comments/Discussion: N/A 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on staff record review and staff interview, the facility failed to ensure that the criminal history report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Upon request, the facility did not provide criminal history reports for staff 7 (hire date, 09/09/2024), staff 8 (hire date, 08/09/2024), and staff 9?s (hire date, 10/21/2024). 2. During the onsite inspection on 07/18/2025, staff 6 confirmed that staff 7 and staff 8?s criminal history report results had not been received. Staff 6 also did not provide documentation of staff 9?s criminal history report.
Based on resident record review, the facility failed to ensure that the use of PRN
Based on record review and staff interview, the facility failed to ensure that all residents who met the criteria for assisted living care, a licensed health care professional, provided health care oversight at least every six months, or more often if indicated. Evidence: 1. Upon request, the facility did not provide a healthcare oversight that was completed at least every six months. 2. During the onsite inspection on 07/18/2025, staff 6 confirmed that the healthcare oversight was not completed at least every 6 months.
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member maintained 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 1?s current certification in first aid was issued by NationalCPRFoundation, expiration 10/30/2025. 2.During the onsite inspection on 07/18/2025, staff 6 confirmed that staff 1?s current certification in first aid was not from any of the required organizations.
Based on record review and staff interview, the facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. The review was documented by signing and dating. Evidence: 1. Upon request, the facility did not provide a semi-annual review of the emergency preparedness and response plan. 2. During the onsite inspection on 07/18/2025, staff 6 confirmed that the emergency preparedness and response plan was not documented as reviewed semi-annually with all staff, residents, and volunteers.
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 3 was prescribed ClonazePAM Oral Tablet 1 MG (start date, 03/28/2025), give 1 tablet by mouth three times a day related to essential tremor (7 AM, 1 PM, and 7 PM). 2. Per resident 3?s June medication administration record ( MAR
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2025 Time in: 2:41 PM Time out: 6:05 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/16/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 149 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents engaging in scheduled activities and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on resident review, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 3?s Cambigan Ophthalmic Solution 0.2-0.5% and Carbidopa-Levodopa Oral Tablet 25-100 MG were scheduled for administration at 1:00 pm. Cambigan Ophthalmic Solution 0.2-0.5% and Carbidopa-Levodopa Oral Tablet 25-100 MG was not documented as administered at 1:00 pm on 04/08/2025 and 04/10/2025, per resident 3?s April 2025 MAR
Based on resident record, the facility failed to ensure that medications were 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. Resident 3 was prescribed Carbidopa-Levodopa Oral Tablet 25-100 MG and Combigan Ophthalmic Solution 0.2-0.5%, which were scheduled to be administered at 1:00 pm. The medications were administered at 5:03 pm on 05/30/2025 per resident 3?s May 2025 MAR
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2025 Time in: 12:54 PM Time out: 2:06 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/02/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 149 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on record review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatened the life, health, safety, or welfare of any resident. Evidence: 1. The facility did not report Resident 2?s hospitalization for a heart attack on 05/30/2025 or their unexpected death on 06/05/2025. 2. On 06/16/2025, staff 1 confirmed that the regional licensing office was not contacted within 24 hours of resident 2?s hospitalization.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2025 Time in: 2:07 PM Time out: 2:40 PM 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 02/28/2025 regarding allegations in the area(s) of: Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 149 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: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities, entering and exiting the community for outings, and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on record review and resident interview, the facility failed to ensure the written emergency preparedness and response plan addressed and analyzed potential hazards of the facility that disrupted normal operation of the facility. Evidence: 1. The facility reported on 02/28/2025 that building 2?s elevator was offline for approximately 3 weeks. The same elevator was previously offline in 10/2024. 2. On 06/16/2025, staff 2 indicated residents were escorted from their respective floors to the main floor by calling the concierge desk for medical and/or community appointments. 3. On 06/16/2025, two collateral contacts confirmed that the elevators were offline for an extended period and that the plan for staff to assist residents to other floors not consistent or followed.
Based on record review, the facility failed to ensure that elevators were kept in good running condition. Evidence: 1. The only elevator in building 2 was offline for approximately 3 weeks.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2024 Time In: 6:06 PM Time Out: 6:20 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/07/2024 regarding allegations in the area(s) of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 145 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed the physical plant of the facility. LI observed residents waiting for staff to assist with utilizing the stairs. LI observed residents interacting with peers and staff. Additional Comments/Discussion: 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 Nina Wilson Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/21/2024 Time In: 10:10 AM Time Out: 4:11 PM 08/22/2024 Time In: 11:54 Time Out: 3:13 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/12/2024 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 8 Observations by licensing inspector: LI observed the physical plant of the facility. LI observed residents engaging in activities, sitting on the porch with peers and staff, participating in community outings, and eating lunch in the dining area. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel, Staffing and Supervision, Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Based on facility record review, the facility failed to ensure that an adequate number of staff persons shall be on the premises at all times to implement the approved fire and emergency evacuation plan. Evidence: 1. The facility has three assisted living facilities (ALF) and one memory care unit on the campus: Shenandoah (staff ratio: 1st shift, 3 employees; 2nd shift, 3 employees, and 3rd shift, 2 employees), Potomac (staff ratio: 1st shift, 3 employees; 2nd shift, 3 employees, and 3rd shift, 2 employees), and James (ALF and Memory Care - staff ratio: 1st shift, 2 employees, 2nd shift, 2 employees, and 3rd shift, 2 employees). 2. June - August 2024?s Shenandoah staff schedule states that 2 employees were scheduled for the 2nd shift on 06/28/2024, 06/30/2024, and 07/01/2024, 07/05/2024, 07/07/2024, 07/08/2024, 07/09/2024, 07/12/2024, 07/14/2024, 07/15/2024, 07/16/2024, 07/18/2024, 07/19/2024, 07/21/2024, 07/25/2024, 07/26/2024, 07/28/2024, 07/29/2024, 07/30/2024, 08/01/2024, 08/02/2024, 08/04/2024, 08/05/2024, 08/06/2024, 08/08/2024, 08/09/2024, 08/11/2024, 08/12/2024, 08/13/2024 and 08/15/2024. 3. June ? August 2024?s Shenandoah staff schedule states that 1 employee was scheduled for the 2nd shift on 07/22/2024, 08/09/2024 and 08/18/2024. 4. June ? August 2024?s Shenandoah staff schedule states that 1 employee was scheduled for the 3rd shift on 08/15/2024, 08/17/2024, and 08/18/2024. 5. June ? August 2024?s Potomac staff schedule states that 2 employees was scheduled for the 1st shift on 07/30/2024. 6. May ? July 2024?s James (Memory Care) staff schedule states that 1 employee was scheduled for the 3rd shift on 05/25/2024 and 07/27/2024. 7. May ? July 2024?s James (Memory Care) staff schedule states that 1 employee was scheduled for the 2nd shift on 05/31/2024. 8. May ? July 2024?s James (Memory Care) staff schedule states that 1 employee was scheduled for the 1st shift on 06/14/2024 and 06/17/2024. 9. May ? July 2024?s James (ALF) staff schedule states that 1 employee was scheduled for the 2nd shift on 05/19/2024, 06/08/2024, 07/04/2024, 07/26/2024, 08/02/2024. 10. May ? July 2024?s James (ALF) staff schedule states that 1 employee was scheduled for the 3rd shift on 05/28/2024, 06/09/2024, 06/10/2024, 06/11/2024, 06/15/2024, 06/18/2024, 06/19/2024, 06/24/2024, 06/29/2024, 06/30/2024, 07/06/2024, 07/21/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/08/2024. 11. May ? July 2024?s James (Memory Care) staff schedule states that 1 employee was scheduled for the 1st shift on 06/18/2024. 12. On 08/21/2024 LI interviewed Staff 9 who explained the staffing plan. Staff 9 stated that there are holes in the schedule that were filled but not updated in the system.
Based on facility record review, the facility failed to ensure that medications were 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. Medication Admin Audit Report, 07/21/2024 ? 08/21/2024 stated that there were 41 late medication administrations recorded for the Assisted Living Facility. 2. Medication Admin Audit Report, 07/25/2024 states that there were 14 instances where medications were scheduled for 7 PM one day but were not documented as administered until 10 AM the next day, 14 hours past the scheduled administration time. 3. Medication Admin Audit Report, 07/25/2024 states that there was 1 instance where medications were scheduled for 9 PM one day but was not documented as administered until10 AM the next day, 12 hours past the scheduled administration time. 4. Medication Admin Audit Report, 08/11/2024 and 08/17/2024 states that there were 2 instances where medications were scheduled for 4 PM one day but were not documented as administered until 9 PM the next day, 4 hours past the scheduled administration time. 5. Medication Admin Audit Report, 08/17/2024 states that there were 9 instances where medications were scheduled for 7 PM and were documented as administered at 11 PM, 3 hours past the scheduled administration time. 6. Medication Admin Audit Report, 08/17/2024 states that there was 1 instance where medications were scheduled for 9 PM and were documented as administered at 11 PM, 2 hours past the scheduled administration time. 7. Medication Admin Audit Report, 08/11/2024 states that there was 1 instance where medications were scheduled for 7 AM and were documented as administered at 10 AM, 2 hours past the scheduled administration time. 8. Medication Admin Audit Report, 07/21/2024 ? 08/21/2024 states that there were 2 instances where medications were scheduled for 4 PM and were documented as administered at 6 PM, 1 hour past the scheduled administration time. 9. Medication Admin Audit Report, 07/21/2024 ? 08/21/2024 states that there were 7 instances where medications were documented as administered between 40 minutes and 1 minute past the scheduled administration time. 10. On 08/22/2024, LI interviewed Staff 9 who stated that counseling was conducted with one employee who documented administering medications late on 17 separate instances.
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