The Warren

Based on resident record review and staff interviews, the licensee failed to ensure compliance with the facility's own policies and procedures. Evidence: 1. A complaint received by the regional licensing office on 11/3/2025 which alleged that ?a resident on the dementia unit has brought in bed bugs and management is doing nothing about it.? 2. Staff 1, 2, 4, 5, and 7 confirmed the previous presence of bed bugs in resident 1?s room. 3. Licensing inspector (LI) was given a copy of the Procedure: Receiving Furniture- Bed Bug Prevention Protocol, which specifies ?upon arrival, furniture must be visually inspected outside of the main building before being brought in?. Procedure also stated that ?furniture may not be immediately placed in rooms? and will be held in a ?designated furniture quarantine area (garage, maintenance shed, or isolated room) for at least 24 hours?. Documentation should include a furniture receiving log, which includes date of arrival, source, inspector?s name, notes on condition, and clearance date and placement location. 4. During an interview with LI on 11/12/2025, staff 3 confirmed that furniture should be inspected prior to move in and a checklist completed. 5. During an interview with LI on 11/12/2025, staff 7 was asked if furniture was moved directly into resident rooms when it arrived. Staff 7 responded, ?Yes, it does.? When LI asked staff 7 if move in checklist was completed, staff 7 responded, ?I did not complete move in checklist?. 6. During an interview with LI on 11/12/2025, staff 2 was asked where the designated furniture quarantine area, such as a garage, maintenance shed, or isolation room was for furniture to stay at least 24 hours per the Procedure: Receiving Furniture- Bed Bug Prevention Protocol. Staff 2 stated that there was not a designated furniture quarantine area on the campus, nor was there room for one. LI referred to procedure and staff 2 acknowledged procedure was not being followed.

Based on resident record review and staff interviews, the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or that threatened the life, health, safety, or welfare of any resident. Evidence: 1. During an interview with LI on 11/12/2025, staff 2 stated that a bed bug was first found in resident 1?s room on 9/24/2025 at 2:46 p.m. Staff 2 provided LI with a picture of the bed bug found by Ecolab pest control. 2. During an interview with LI on 11/12/2025 when asked if the facility reported the presence of the bed bug to regional licensing office, staff 2 stated, ?I did not report to DSS (Department of Social Services), because it was not an outbreak. When LI asked if bed bug was reported to the health department, staff 2 stated, ?I didn?t know I needed to.?

Based on resident record review and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. A complaint received by the regional licensing office on 11/3/2025 alleged that ?a resident on the dementia unit has brought in bed bugs and management is doing nothing about it.? 2. Resident 1 moved into the community on 8/27/2025. 3. During a phone interview with LI on 11/12/2025, Ron Davis with Ecolab confirmed the presence of bed bugs in resident 1?s room on September 24, 2025, and October 21, 2025. LI asked Ron Davis with Ecolab if there was any way to prevent bed bugs from entering the building during the move in process, and he stated that leaving furniture isolated for a week will prevent bed bugs from entering the facility because bed bugs need people to survive and do so by coming out at night to bite and feed. If the bed bugs are unable to bite people and get nourishment, the bed bugs will die. 4. During interview with LI on 11/12/2025, staff 2, 3, and 7 acknowledged that the facility failed to follow the Procedure: Receiving Furniture- Bed Bug Prevention Protocol. By doing so, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Based on staff record review and staff interview, the facility failed to ensure direct care staff, within four months of the starting date of employment, attended six hours of training in working with individuals who have cognitive impairments. Evidence: 1. Staff 7, hired 1/20/2025, had only one hour of documented training for individuals with cognitive impairments. 2. Staff 9, hired 5/27/2025, had only one hour of documented training for individuals with cognitive impairments. 3. During an interview with the LI on 9/15/2025, staff 5 confirmed the facility did not ensure that staff 7 and 9 attended six hours of documented training for individuals with cognitive impairments.

Based on staff record reviews and staff interview, the facility failed to ensure personal and social data was maintained on staff and included in the staff record. Evidence: 1. Record for staff 7, hired 1/20/2025, did not contain the required personal and social data. 2. Record for staff 8, hired 7/29/2025, did not contain the required personal and social data. 3. Record for staff 9, hired 5/27/2025, did not contain the required personal and social data or verification that the employee received a copy of the current job description. 4. During an interview with LI on 9/15/2025, staff 5 confirmed the only personal and social information/data collected upon hire was on the employee application which did not include all of the required information such as employee?s date of birth or name and phone number of the emergency contact. Staff 5 also confirmed the facility did not have verification that staff 9 had received a copy of the required job description.

Based on staff record reviews and staff interview, the facility failed to ensure direct care staff members maintained current certification in first aid. Evidence: 1. Record for staff 7, hired 1/20/2025, did not contain current first aid certification. 2. Record for staff 9, hired 5/27/2025, did not current first aid certification. 3. During an interview with LI on 9/15/2025, staff 5 was unable to provide verification that staff 7 and 9 maintained current certification in first aid.

Based on staff record reviews and staff interview, the facility failed to ensure there was at least one staff person in the building at all times who had current certification in Cardiopulmonary Resuscitation (CPR). 1. Record for staff 7, hired 1/20/2025, did not contain a current CPR certification certificate. 2. Record for staff 9, hired 5/27/2025, did not contain a current CPR certification certificate. 3. On the 6 a.m. to 2 p.m. shift on 8/31/2025, 9/13/2025, and 9/14/2025, staff 7 and 9 were the only staff listed on the schedule. 4. During an interview with the LI on 9/15/2025, staff 5 was unable to provide verification that staff 7 and 9 maintained current certification in CPR as required.

Based on record review and staff interview, the facility failed to have staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans.'' Evidence:'' 1. On the day of inspection, 9/15/2025, two licensing inspectors were present on the Sage unit from 9:45 a.m. until 9:58 a.m. This unit utilizes a WanderGuard pendant system. The registered medication aid (RMA) arrived on the unit at 9:52 a.m. The direct care aid (DCA) arrived on the unit at 9:58 a.m. For eight minutes, there were no staff members present. 2. During the eight minutes when no staff members were present, resident 2 was observed going into other resident?s rooms, disrobing down to their incontinence brief, which appeared soiled, continuing to wander in the hallway and into another resident?s room. 3. During an interview on 9/17/2025 with staff 13, when asked if there was a DCA assigned on the Sage unit, staff 13 stated ?nobody was on the unit this morning?, due to providing care to a resident on assisted living. When asked about the needs of residents on the Sage unit, staff 13 stated that out of the 18 residents, six are a two- person assist and two have wandering/aggressive behaviors. Staff 13 stated, ?It?s hard to take care of this building with three staff, and we only have three staff all the time; only two DCAs and one med tech (RMA).? ' 4. During an interview with staff 3 when asked how many staff were scheduled, staff 3 stated they began working at The Warren in February and since then there had consistently only been two DCAs. Occasionally there had been a third DCA scheduled, but that was rare. Staff 3 stated all residents were heavy care and the ?staff ratio was not enough to care for people?. 5. During an interview with staff 4, when asked about staffing, staff 4 stated they had worked at the facility for seven months, and there were consistently two DCAs and a med tech (RMA). Staff 4 stated they rarely had a third DCA scheduled from 5 to 9 p.m. Staff 4 stated that out of ?36 residents more than 10 need two people and almost all on Sage needed two- people?. LI asked staff 4 what happened if someone on assisted living required two people, and staff 4 stated, ?Sage are left unattended?. 6. While staff 13 was passing medications on assisting living and staff 3 and 4 were caring for a two person assist on assisted living, there was no staff on duty on the Sage unit to provide care or oversight/redirection to the residents in care. During this time the facility failed to ensure staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of the residents.

Based on resident record review and staff interview, the facility failed to provide written assurance to the resident that the facility had the appropriate license to meet his care needs at the time of admission with a signed copy of the written assurance retained in the resident?s record. Evidence: 1. Record for resident 1, admit date 5/2/2025, did not contain a written assurance that was signed by the resident or legal representative. 2. Record for resident 2, admit date 4/2/2025, did not contain a written assurance that was signed by the resident or legal representative. 3. Record for resident 4, admit date 2/22/2025, did not contain a written assurance that was signed by the resident or legal representative. 4. Staff 5 presented the resident admission agreement page for residents 1, 2, and 4 as what is used to fulfill this standard, but it did not contain the required information. 5. During interview with LI on 9/15/2025, staff 5 confirmed they did not provide written assurances to residents 1, 2, and 4.

Based on record reviews and staff interview the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record this was ascertained and the date the information was obtained. Evidence: 1. Record for resident 1, admitted 5/2/2025, did not contain evidence of a registered sex offender search. 2. During an interview with the LI on 9/15/2025, staff 5 confirmed the facility failed to ascertain, prior to admission, whether a resident 1 was a registered sex offender and document in resident 1?s record this was ascertained and the date the information obtained.

Based on resident record review and staff interview, the facility failed to provide an orientation, upon admission, for new residents and their legal representatives, which included emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation must be and dated by the resident and, as appropriate, his legal representative, with documentation kept in the resident's record. Evidence: 1. Record for resident 1, admit date 5/2/2025, did not contain a documented orientation that was signed by the resident or legal representative. 2. Record for resident 2, admit date 4/2/2025, did not contain a documented orientation that was signed by the resident or legal representative. 3. Record for resident 4, admit date 2/22/2025, did not contain a documented orientation that was signed by the resident or legal representative. 4. Staff 5 presented an acknowledgement of the resident handbook as what was used to comply with this standard, but this document does not contain the required information. 5. During an interview with the LI on 9/15/2025, staff 5 confirmed there was no documented orientation for residents 1, 2, and 4 and their respective legal representatives, which included emergency response procedures, mealtimes, and use of the call system.

Based on record review and staff interview the facility failed to ensure that the preliminary plan of care was developed to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident. Evidence: 1. Record for resident 1, admitted 5/2/2025, did not contain a preliminary plan of care. 2. During an interview with the LI on 9/15/2025, staff 5 acknowledged the facility failed to ensure the preliminary plan of care was developed to address the basic needs of resident 1.

Based on record review and staff interview, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest were only carried out in a licensed assisted living facility when both a valid written order had been issued by the resident's attending physician and the written order was included on the individualized service plan. Evidence: 1. Resident 4, admitted 2/22/2025, had a signed physician?s Do Not Resuscitate (DNR) order dated 2/26/2025. 2. Individualized service plan ( ISP

Based on observation and staff interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During a tour of the facility on 9/15/2025, two licensing inspectors observed maintenance and cleaning supplies, including Pro-treat for condensate drain pans, Crystal stain block, WD-40, and Magnum blue pre-spotter degreaser, in an unlocked housekeeping closet marked biohazard. 2. During an interview with the LI on 9/15/2025, staff 5 confirmed the facility failed to store cleaning supplies and other hazardous materials in a locked area. 3. Photo evidence taken.

Based on record review and staff interview, the facility failed to document rounds that were made for residents with an inability to use the signaling device. Evidence: 1. During an interview on 9/15/2025, the Licensing Inspector (LI) asked staff 6 if residents 2 and 4 were able to use a signaling device. Staff 6 responded, ?no?. 2. LI requested documentation of rounds completed on resident 2 and 4. 3. During a follow-up interview with the LI, staff 6 confirmed the documentation of rounding for residents with an inability to use the signaling device was not being completed.

Based on resident record review and staff interview, the facility failed to ensure a complete first aid kit was on hand at the facility and contained all the required items as listed in the subsection. Evidence: 1. The facility first aid kit was inventoried and missing adhesive tape and band-aids in assorted sizes. 2. During an interview with the LI on 9/15/2025, staff 5 confirmed that the facility first aid kit did not contain all of the required elements.

Based on staff record reviews and staff interview, the facility failed to obtain an original criminal history record report for each employee within 30 days of employment. Evidence: 1. The Licensing Inspector (LI) requested all criminal history record reports (CHRR) for all new staff hired since the last mandated inspection on 10/9/2024. 2. Staff 10, hired 11/30/2024, contained a CHRR dated 9/15/2025 (date of the inspection). 3. Staff 11, hired 5/13/2025, contained a CHRR dated 9/15/2025 (date of the inspection). 4. Staff 12, hired 5/6/2025, contained a CHRR dated 9/15/2025 (date of the inspection). 5. During an interview with the LI on 9/15/2025, staff 5 acknowledged the facility ran the CHRRs for staff 10, 11, and 12 on the day of the inspection and thus failed to obtain the required reports within 30 days of employment as required by the standard.

Based on self-reported incident and resident record review, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Self-reported incident from the facility stated resident 1 missed doses of hydrocodone 5/325mg from 4/10/2025-4/17/2025. 2. The Medication Administration Record ( MAR

Based on resident record review, the facility failed to submit a written report of each incident specified in 22VAC40-73-70-A to the regional licensing office within seven days from the date of the incident. Evidence: 1. Regional licensing office received incident reports for resident 1 on 11/18/2024 and 1/7/2025. 2. LI received an email from staff 1 on 11/18/2024 reporting an initial incident with resident 1. The final written report for the incident was sent to the LI on 11/29/2024, which is beyond the seven-day reporting requirement. 3. LI received an email from staff 1 on 1/7/2025 reporting an initial incident with resident 1. The final written report on the incident was sent to LI on 1/18/2025, which is beyond the seven-day reporting requirement.

Based on resident record review and staff interview, the facility failed to maintain a method of written communication between direct care staff on all shifts of significant happenings, problems, complaints, injuries, and incidents experienced by residents with the written communication retained for at least two years and the information included in the record of the involved resident. Evidence: 1. During review of resident 1?s medication administration record ( MAR

Based on resident record review and staff interviews, the facility failed to ensure the individual's needs could be met prior to admission by reviewing, at a minimum, a completed Uniform Assessment Instrument, a physical examination report, and completing a documented interview between administrator, the individual, and his legal representative. Evidence: 1. The Uniform Assessment Instrument ( UAI

Based on resident record review and staff interview, the facility failed to provide a written assurance to the resident that the facility had the appropriate license to meet the care needs of the resident at the time of admission. Evidence: 1. The record for resident 1 did not contain a written assurance. 2. During an interview with the LI on 7/2/2025, staff 1 was unable to confirm that a written assurance was provided to resident 1 to ensure the facility had the appropriate license to meet his care needs at the time of admission.

Based on resident record review and staff interviews, the facility failed to obtain a physical examination by an independent physician within 30 days preceding admission. Evidence: 1. The admission date for resident 1 was 7/12/2024. The physical examination report for resident 1 was dated 10/28/2024. 2. During an interview on 7/2/2025, staff 1 and staff 2 confirmed that the facility failed to obtain a physical examination for resident 1 prior to admission.

Based on resident record review and staff interview, the facility failed to conduct a mental health screening prior to admission if behaviors or patterns of behavior caused or continued to cause concern for the health, safety, or welfare of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident 1?s record did not contain a mental health screening. 2. During an interview with the LI on 7/2/2025, staff 1 confirmed there was no mental health screening and one had not been completed prior to admission.

Based on resident record review and staff interview, the facility failed to conduct a mental health screening when a resident displayed behaviors or patterns of behavior indicative of behavioral disorders that caused concern for the health, safety, or welfare of either that resident or others who could be placed at risk of harm by the resident. Evidence: 1. Progress note for resident 1 dated 8/3/2024 stated, ?Resident was attempted [sic] to be redirected due to him getting aggressive? but no mental health screening was conducted. 2. On 11/18/2024, facility notified the LI that resident 1 became aggressive with a staff member. Resident record did not contain information about a mental health screening at that time. 3. During an interview with LI on 7/2/2025, staff 1 confirmed that the mental health screening was not completed as required.

Based on resident record review and staff interviews, the facility failed to determine the appropriateness of the admission, for an individual with behavioral disorders, by obtaining information about the individual's psychosocial and behavioral functioning from primary sources, such as family members, friends, or physician and documenting the source and content of the information obtained. Evidence: 1. Resident 1?s record did not contain documentation that information regarding psychosocial and behavioral functioning was gathered from primary sources to determine the appropriateness of the admission. 2. During an interview with the LI on 7/2/2025, staff 1 and 2 confirmed there was no documentation regarding psychosocial and behavioral functioning gathered from primary sources which was to be used to determine the appropriateness of the admission.

Based on resident record review and staff interviews, the facility failed to document any notable changes in condition, functioning, or altered behavior and the corresponding actions taken along with the appropriate assistance provided when the resident has observable unmet needs. Evidence: 1. 24-hour report dated 7/23/2024 indicated that resident 1 was walking into other resident rooms. There was no documentation of corresponding action taken or assistance provided to the resident. 2. 24-hour report dated 7/30/2024 indicated that resident 1 got aggressive while pushing another resident. There was no documentation of corresponding action taken or assistance provided to the resident. 3. 24-hour report dated 9/2/2024 indicated that resident 1 kept stating he was leaving due to being tired of being at facility. There was no documentation of corresponding action taken or assistance provided to the resident. 4. 24-hour report dated 9/25/2024 indicated that resident 1 had a pocketknife. There was no documentation of corresponding action taken or assistance provided to the resident. 5. During an interview with LI on 7/2/2025, staff 1 and 2 confirmed that there was no documentation of the corresponding actions taken or assistance provided to the resident for each of the incidents listed on the 24-hour report.

Based on resident record review and staff interview, the facility failed to retain a complete resident record for at least two years following discharge. Evidence: 1. Resident 1, admitted 7/12/2024, was discharged from the facility on 1/7/2025. 2. During the inspection on 7/2/2025, LI requested resident 1?s complete resident record. Staff 1 provided a photocopied stack of documents which contained no original documents with no original signatures and confirmed to the LI what was provided was resident 1?s complete medical record. 3. After reviewing the provided documentation, licensing staff requested the following items: a. Original documents for the photocopies that were provided b. Physical examination preceding admission c. Mental Health Screening d. Sex Offender Information e. All signed physician orders from 7/12/2024 through 1/7/2025 f. All facility progress notes from 7/12/2024 through 1/7/2025 g. All physician progress notes from 7/12/2024 through 1/7/2025 h. Any additional required assessments completed which were not provided originally 4. Staff 1 was able to provide a physical exam dated 10/28/2024 (resident 1?s admit date was 7/12/2024), one photocopied signed physician?s order dated 7/31/2024, and one facility progress note dated 8/3/2024. 5. During an interview with the LI and LA on 7/2/2025, staff 1 confirmed they failed to retain a completed resident record and were unable to provide any additional signed physician's orders, physician?s progress notes or any additional facility progress notes and were not able to provide any original documents as requested for resident 1.

Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident 1 contained one signed physician's order dated 7/31/2024 for naltrexone 50 mg tablet 1 tablet by mouth daily to start on 7/31/2024. 2. Naltrexone 50 mg tablet did not appear on any of the medication administration records ( MAR

Based on resident record review and staff interview, the facility failed to immediately report suspicions of abuse, neglect or exploitation of an aged or incapacitated adult. Evidence: 1. Incident dated 7/30/2024 at 2:30 p.m. indicated that resident 1 attempted to put his hands down resident 2?s shirt. Documentation provided indicated there was previous history of these types of incidents specifically resident 1 was previously caught kissing resident 2. 2. During an interview with the LI, staff 1 confirmed resident 2 was unable to tell what happened during the incident on 7/30/2024 due to a diagnosis of dementia and also stated resident 2 was in a wheelchair and unable to move the wheelchair independently. During the same interview staff 2 added that resident 2 was verbal but ?doesn?t make sense?. 3. Internal facility documentation dated 7/30/2024 indicated the POA for resident 1 was notified. During an interview with the LI staff 1 stated the POA for resident 2 was also notified by phone but there was no documentation that such notification had been made. The same report also listed preventative steps to include one on one, documentation in the resident service notes, educate resident, setting boundaries, medication review, and frequent safety checks to ensure both residents are safe. 4. During an interview with the LI, staff 1 confirmed the facility failed to immediately report the incident of possible abuse to Adult Protective Services as required by Code.

Based on resident record review and staff interview, the facility failed to ensure the resident was free of physical or mechanical restraints except in the following situations and with appropriate safeguards: a. as necessary for the facility to respond to unmanageable behavior in an emergency situation, which threatens the immediate safety of the resident or others; b. as medically necessary, as authorized in writing by a physician, to provide physical support to a weakened resident. Evidence: 1. The MAR

Based on facility records, resident records and staff interviews, the facility failed to have staff adequate in knowledge, skill and abilities and sufficient in number to provide services to attain and maintain the physical, mental and psychological well-being of each resident. Evidence: 1. LI asked Staff 5 if there was a sufficient number of direct care staff to care for the residents, staff 5 stated: if everything flows, it is not an issue, but if a resident falls, or if a resident returns from the hospital, or if there are treatments or a family member has a question or concern we do not have a sufficient amount of direct care staff. LI asked how often the forementioned occurrences happen in a week and staff 5 stated 2-3 times a week. 2. Staff 5 stated: there?s no way for one person to pass medications within the two-hour window, it is impossible. 3. LI asked Staff 6 if there was enough direct care staff to care for the residents, staff 6 stated: there is no way we can get to call lights when we are helping residents that need two people to assist them. Census needs to increase before another staff member can be hired. 4. LI asked Staff 7 if there was a sufficient number of direct care staff to care for the residents, staff 7 stated: it is debatable, some days are good and some days aren?t, there are call bell delays, we have to speed up, we can?t spend time with residents, we need to get to the next resident. Care is given, just delayed because we are caring for others (residents). 5. LI asked Staff 8 if there was a sufficient number of direct care staff to care for the residents, staff 8 stated: No, the girls are running around, medications are not passed timely, too many residents to pass medications to. 6. Between 3/8/2025-3/19/2025, Resident 8?s March Medication Administration Record indicated she received 15 prescribed medications after facility?s dosing schedule. 7. There were 20 instances, according to the Building Escalation Detailed Event Report (call bell history report) for 3/14/2025-3/15/2025, in which it took staff more than 15 minutes to respond to the resident?s call bell

Based on resident record review, the facility failed to develop an Individualized Service Plan that included a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. Evidence: 1. Resident 4 had a physician?s order to insert foley catheter written on 3/5/2025. 2. Resident 4?s Individualized Service Plan developed on 12/1/2024 was not updated to include a description of needs related to the foley catheter.

22VAC40-73-460B Based on facility record review, the facility failed to respond promptly to resident needs. Evidence: 1. The Building Detailed Escalation Event Report (call bell history report) for Resident 9 indicates 5 instances in which it took staff more than 15 minutes to respond to the resident?s call bell at on 3/14/2025 at 12:12am (19 mins), 8:50am (29 mins), 7:17pm (29 mins) and on 3/15/2025 at 1:59am (18 mins) and at 11:48pm (60 mins). 2. The Building Detailed Escalation Event Report (call bell history report) for Resident 10 indicates 2 instances in which it took staff over 15 minutes to respond to the resident?s call bell on 3/14/2025 at 2:56am (26 mins) and at 8:34pm (33 mins). 3. The Building Detailed Escalation Event Report (call bell history report) for Resident 12 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/15/2025 at 4:31am (69 mins). 4. The Building Detailed Escalation Event Report (call bell history report) for Resident 11 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/14/2025 at 11:04am (30 mins). 5. The Building Detailed Escalation Event Report (call bell history report) for Resident 2 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/14/2025 at 12:10pm (41 mins). 6. The Building Detailed Escalation Event Report (call bell history report) for Resident 13 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/14/2025 at 12:16pm (42 mins). 7. The Building Detailed Escalation Event Report (call bell history report) for Resident 6 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/14/2025 at 1:20pm (19 mins). 8. The Building Detailed Escalation Event Report (call bell history report) for Resident 14 indicates 2 instances in which it took staff over 15 minutes to respond to the resident?s call bell on 3/14/2025 at 8:43pm (19 mins) and on 3/15/2025 at 9:34am (15 mins). 9. The Building Detailed Escalation Event Report (call bell history report) for Resident 15 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/15/2025 at 1:03am (24 mins). 10. The Building Detailed Escalation Event Report (call bell history report) for Resident 17 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/15/2025 at 11:17pm (102 mins). 11. The Building Detailed Escalation Event Report (call bell history report) for Resident 4 indicates 1 instance in which it took staff over 15 minutes to respond to the resident?s call bell on 3/15/2025 at 11:47pm (42 mins).

22VAC40-73-680C Based on resident record review, the facility failed to administer medications not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: 1. Resident 8?s March 2025 Medication Administration Record indicated Preservision ARed Tablets , take 1 tab by mouth two times a day for supplement, prescribed on 1/23/2025 scheduled for 6:00am and 6:00pm were documented as administered at the following times: 3/8/2025 (7:51am), 3/9/2025 (9:12pm), 3/11/2024 (7:13am and 7:54pm), 3/12/2025 (7:07am), 3/13/2025 (10:23am and 7:09pm), 3/14/2024 (7:07pm), 3/15/2025 (8:08pm), 3/16/2025 (8:02pm), and 3/17/2025 (7:09am and 8:02pm). 2. Resident 8?s March 2025 Medication Administration Record indicated Alprazolam 0.25 mg tablet , take 1 tablet by mouth twice a day at 7:00am and 7:00pm, prescribed 2/7/2025 were documented as administered at the following times: 3/15/2025 (8:08pm), and on 3/17/2025 (8:02pm).