Veitch Street Alf

Based on record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. Evidence: 1. During the onsite inspection, licensing inspector (LI) reviewed incident reports since 09/2024. The review of the incident reports indicated that a resident experienced a seizure resulting in emergency services rendering medical aide (10/02/2024); a resident experienced an unwitnessed fall with injury (10/23/2024), a resident experienced an unwitnessed fall with injury (10/29/2024); resident experienced a fall with injury (01/21/2025); and a resident tested positive with COVID-19 on 08/25/2025. 2. The incidents that occurred on 10/02/2024, 10/23/2024, 10/29/2024, 01/21/2025, and 08/25/2025 were not reported to the regional licensing office at any time. 3. During the onsite inspection, 10/02/2025, staff 4 confirmed that the incidents that occurred on 10/02/2024, 10/23/2024, 10/29/2024, 01/21/2025, and 08/25/2025 affected the health and welfare of the residents and were not reported to the regional licensing office within 24 hours.

Based on record review and staff interview, the facility failed to offer residents a varied mix of weekly activities including those that are physical; social; cognitive, intellectual, or creative; productive; sensory; reflective or contemplative; involve nature or the natural world; and weather permitting, outdoor activity. Any given activity may involve more than one of these. Community resources as well as facility resources may be used to provide activities. Evidence: 1. October 2024?s activity calendar indicated the following activities: listen to music (daily, 1 hour), meditate exercise (30 minutes, 4 times/month), write in journal (30 minutes, 4 times/month), library (1 hour, 2 times/month), movie night (2 hour, 1 time/month), community outing (2 hour, 2 times/month), bingo night (30 minutes, 4 times/month), and sip and paint (30 minutes, 1 time/month). 2. During the onsite inspection, staff 4 confirmed that October 2024?s activity calendar did not include a varied mix of weekly activities including those that are physical; social; cognitive, intellectual, or creative; productive; sensory; reflective or contemplative; involve nature or the natural world; and weather permitting, outdoor activity.

Based on resident record review and staff interview, the facility failed to ensure that medications ordered for PRN

Based on resident record review and staff interview, the facility failed to ensure that the licensee, administrator, or his designee who successfully completed the department-approved individualized service plan ( ISP

Based on record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section were reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person. Evidence: 1. Upon request, the facility did not provide documentation that the procedures for resident emergencies were reviewed semi-annually with all staff. 2. During the onsite inspection, 10/02/2025, staff 4 confirmed that the procedures for resident emergencies was not documented as reviewed with all staff, every six months.

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

Based on record review and staff interview, the facility failed to ensure that at least every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced. Documentation of each exercise should be maintained in the facility for at least two years. Evidence: 1. Upon request, the facility did not provide documentation that all staff on duty on each shift participated in an exercise in which procedures for resident emergencies were practiced every six months. 2. During the onsite inspection, 10/02/2025, staff 4 confirmed that procedures for resident emergencies were not practiced every six months by all staff currently on duty on each shift.

Based on record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff and residents, with emphasis placed on an individual?s respective responsibilities. The review should be documented by signing and dating. Evidence: 1. The emergency preparedness and response plan was reviewed with staff on 09/10/2025. The emergency preparedness and response plan was not reviewed prior to 09/10/2025. 2. During the onsite inspection, 10/02/2025, staff 4 confirmed that the emergency preparedness and response plan was not documented as reviewed with staff and residents semi-annually.

Based on resident review and staff interview, the facility failed to ensure that medication aides administered the PRN

Based on record review and staff interview, the facility failed to ensure that when licensed for both residential and assisted living care, there were at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day. Evidence: 1. October 2024?s activity calendar indicated that there were 8 hours of activities scheduled the week of 10/01-05/2024; 10.5 hours scheduled the week of 10/06- 12/2024; 10 hours scheduled the week of 10/13-19/2024; 12 hours scheduled the week of 10/20-26/2024; and 5.5 hours the week of 10/27-31/2024. 2. January 2025?s activity calendar indicated that there were 0 hours scheduled on 01/01/2025; 6 hours scheduled the week of 01/02-05/2025; 11 hours scheduled the week of 01/06-12/2025; 11 hours scheduled the week of 01/13-19/2025; 11 hours the week of 01/20-26/2025; and 6 hours the week of 01/27-31/2025. 3. May 2025?s activity calendar indicated that there were 6 hours of activities scheduled the week of 05/01-03/2025; 6 hours of activities scheduled the week of 05/04-09/2025; 0 hours of activities scheduled on 05/10/2025; 10 hours of activities scheduled the week of 05/18- 23/2025; 0 hours of activities scheduled on 05/24/2025; and 9 hours of activities scheduled the week of 05/25-31/2025. 4. During the onsite inspection, 10/02/2025, staff 4 confirmed that October 2024, January 2025, and May 2025?s activity calendars did not have at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day.

Based on licensing inspector (LI) observation and staff interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that was conspicuous to the residents and the public. Evidence: 1. On 09/23/2024, LI observed a posting with the permanent staff names and titles. The posting did not include the name of the current on-site person in charge. 2. On 09/23/2024, LI interviewed Staff 2 who confirmed that there was not a procedure for posting the on-site person in charge for each day. 3. On 09/23/2024, LI interviewed Staff 2 who stated that the employees know that the more senior staff on shift would be the manager on duty when the team lead, and directors are not on-site.

Based on LI observation, the facility failed to ensure that the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 09/23/2024, LI toured the facility and observed broken blinds on the sunroom floor, laying against the wall. 2. On 09/23/2024, LI interviewed Staff 2 who confirmed that there were broken blinds on the sunroom floor. 3. On 09/23/2024, LI toured the facility and observed a wooden plank leaning against the wall in the sunroom. 4. On 09/23/2024, LI interviewed Staff 2 who confirmed that a wooden plan was leaning against the wall in the sunroom.

Based on facility record review, the facility failed to ensure that each assisted living facility shall retain a licensed health care professional who has at least two years of experience as a health care professional to provide on-site health care oversight. For residents who meet the criteria for assisted living care: the licensed health care professional, practicing within the scope of the health care professional?s profession, shall provide health care oversight at least every three months. Evidence: 1. Healthcare Oversight was completed every six months, with a start date of, 06/01/2023 and end date of, 11/27/2023. The following Healthcare Oversight had a start date of 11/28/2023 and an end date of 05/28/2024, the healthcare oversight did not contain a list of resident names and was not completed every three months. 2. On 09/23/2024, LI interviewed Staff 3 who stated all residents at the facility were residential. Residential residents are required healthcare oversight every 6 months. 3. On 09/24/2024, LI received an email from Staff 3 which stated, ?With regards to the Healthcare Oversight, I misspoke, as I now see that some of the County case managers have just inadvertently marked their clients as ?assisted? living level of care even though the UAI

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 2 (admit date, 09/29/2023) had an order for Anoro Ellipta 62.5-25 MCG INH (2 puff inhaled into lungs every day for COPD). 2. Resident 2?s July 2024 MAR

Based on facility record review, the facility failed to ensure that the individualized service plan was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. The review and update was performed by a staff person with the qualifications and in conjunction with the resident and, as appropriate, with the resident?s family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: 1. Resident 2?s (admit date, 09/29/2023) individualized service plan ( ISP

Based on licensing inspector (LI) observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, were kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. Evidence: 1. On 09/23/2024, LI toured the facility and observed duct tape securing the soap dispenser to the wall. 2. On 09/23/2024, LI interviewed Staff 2, who confirmed that the duct tape was securing the soap dispenser to the wall. Staff 2 stated it had been that way since the facility opened. 3. On 09/23/2024, LI toured the facility and observed an unclean toilet. The toilet had brown stains inside the toilet, as well as around the bottom seal of the toilet. 4. On 09/23/2024, LI interviewed Staff 2, who stated that the landlord had been contacted concerning the basement bathroom, but the landlord has not yet responded. 5. Photo evidence was taken.

Based on facility record review, the facility failed to ensure to maintain a letter from the agency when temporary agencies were utilized for the provision of substitute staff. Evidence: 1. Staff 1?s (hire date, 07/2023) record did not include a criminal background check completed by the Virginia State Police. 2. On 09/23/2024, Staff 3 confirmed that Staff 1 was a temporary staff from a staffing agency and staff 1?s record did not include a criminal history report completed by the Virginia State Police.

Based on LI observation, the facility failed to ensure that all interior and exterior areas were adequately lighted for safety and comfort of residents and staff. Evidence: 1. On 09/23/2024, LI toured the facility and observed that the lightbulb was not working in the laundry room. 2. On 09/23/2024, LI interviewed Staff 2 who stated that the ceiling was too high to reach and had put in a request for the lightbulb to be changed. 3. Photo evidence was taken.

Based on resident record review and staff interview, the facility failed to ensure that the assisted living facility ascertained, prior to admission, whether a potential resident was a registered sex offender if the facility anticipated the potential resident would have a length of stay greater than three days or in fact stays longer than three days and documented in the resident?s record that this was ascertained and the date the information was obtained. Evidence: 1. Resident 1?s (admit date, 06/01/2023) record did not contain documentation of a sex offender search. 2. On 09/23/2024, LI interviewed Staff 3 who stated that the facility had a change of ownership. Staff 3 stated that the former management company was reluctant to provide certain information. Staff 3 stated that the facility does not have a lot of the admission documentation for this reason. 3. Resident 2?s (admit date, 09/29/2023) records did not contain documentation of a sex offender search.

Based on facility record review and staff interview, the facility failed to maintain a written work schedule that included the name and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time and failed to maintain copies of the schedule for two years. Evidence: 1. September 2024?s work schedule was written on a whiteboard. The work schedule did not include the job classifications of each staff member listed. 2. There were no previous schedules on-site. 3. September 2024?s work schedule did not include Staff 2. 4. On 09/23/2024, LI interviewed Staff 2 who confirmed not being listed on the schedule. Staff 2 stated being on vacation the third week of September and needing to add Staff 2?s name the last week.

Based on staff record review, the facility failed to ensure that two out of the two records reviewed 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. Staff1?s (hire date, 07/2023) first aid certification was issued by National CPR Foundation, 09/21/2024. 2. Staff 2?s (hire date, 05/17/2023) first aid certification was issued by National CPR Foundation, 12/10/2022. 3. On 09/23/2024, LI interviewed Staff 2 who stated, the county is facilitating a CPR/First Aid course soon. Staff 2 stated a plan to participate in this training.

Based on facility record review and staff interview, the facility failed to ensure 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. On 09/23/2024, the LI requested incident report documentation since the last inspection. 2. Resident 1?s (admit date, 06/01/2023) Clozabam 20 mg was documented as administered on 06/03/2023 at 8:30 pm. Resident 1?s Clozabam 20 mg was scheduled to be administered at 8:00 am. This report was not provided to licensing within 24-hours of the incident.

Based on facility record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff and residents with emphasis placed on an individual?s respective responsibilities. Evidence: 1. Upon request the facility did not provide evidence of an annual and semi-annual review of the emergency preparedness and response plan. 2. On 09/23/2024, licensing inspector (LI) interviewed Staff 3 who confirmed that the semi-annual review of the emergency preparedness and response plan was not completed.

Based on the facility record review and staff interview, the facility failed to ensure that a record of the required fire and emergency evacuation drills were kept in the facility for two years. Such record did not include any special conditions simulated. Evidence: 1. August 2023 ? May 2024 fire drill forms titled ?Emergency Preparedness Drill Report? did not contain space for documentation for special conditions simulated. 2. On 09/23/2024, licensing inspector (LI) interviewed Staff 3 who confirmed that the fire drill forms did not contain space for documentation for any special conditions simulated.

Based on staff record review, the facility failed to ensure that health information required by these standards were maintained at the facility and included in the staff record for each staff person, and also were maintained at the facility for each household member who came in contact with residents. Each staff person required to be evaluated should annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Staff 1?s (hire date, 07/2023) tuberculosis screening, 09/27/2022 was completed 11 months prior to hire date.

Based on facility record review, the facility failed to ensure that a method of written communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. April 15 ? June 1, 2024?s communication log was not completed by staff on any shift. 2. The communication log was completed on second shift (4 pm ? 12 am) on 06/04/2024; second shift on 07/01/2024; and on 8/16/2024 (shift not identified). 3. The communication log was not completed from 08/16/2024 ? 09/23/2024 by staff on any shift. 4. On 09/23/2024, LI interviewed Staff 2 who stated that majority of the staff are temporary from a staffing agency. Staff 2 stated, ?they often will use end of shift notes.? LI requested Staff 2 to provide end of shift notes for 09/18/2024 and 09/22/2024. Staff 2 confirmed that the third shift (12 am ? 8 am) completed end of shift notes within the electronic system for those days but the first (8 am ? 4 pm) and second shift (4 pm ? 12 am) did not.