Suite Living Senior Care of VA

Summary: MDH found the licensee failed to ensure the resident record included documentation of all provided services for three of three residents (R1, R2, R3), and failed to document the disposition of medications for one of one resident (R4), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included documentation of all provided services for three of three residents (R1, R2, R3), and failed to document the disposition of medications for one of one resident (R4), with records reviewed. [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation. This has the potential to directly affect the health, safety, and well-being of all residents and staff. [...]”

Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

Summary: MDH found the licensee failed to provide the minimum number of fire and evacuation drills.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide the minimum number of fire and evacuation drills. This has the potential to directly affect the safety of all residents, staff, and visitors. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to develop and execute a written assisted living contract with the required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for three of three residents (R1, R2, R3) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to offer the opportunity to identify a designated representative for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the opportunity to identify a designated representative for three of three residents (R1, R2, R3) with records reviewed. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect the twenty-eight (28) residents residing in the facility and future residents. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed a reassessment for a change in condition for one of five residents (R5) with records reviewed.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment for a change in condition for one of five residents (R5) with records reviewed. [...]”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for three of three residents (R1, R2, R3), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for three of three residents (R1, R2, R3), with records reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed an individualized medication management plan with the required content for three of three residents

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) developed an individualized medication management plan with the required content for three of three residents (R1, R2, R3), with records reviewed. [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure medications were administered per providers orders for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered per providers orders for three of three residents (R1, R2, R3) with records reviewed. [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer directions by storing medications in a refrigerator that were indicated to be stored at room temperature, and failing to maintain a temperature log to ensure appropriate storage of refrigerated medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were stored according to manufacturer directions by storing medications in a refrigerator that were indicated to be stored at room temperature, and failing to maintain a temperature log to ensure appropriate storage of refrigerated medications. This had the potential to affect eight (8) residents with medications stored in the refrigerator. [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to provide documentation in the

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include quantity and names of staff and other individuals involved in the disposition of medications for one of one discharged resident (R4) with record reviewed. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed a treatment management plan to include all required content for two of two residents (R1, R2) with treatment services records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) developed a treatment management plan to include all required content for two of two residents (R1, R2) with treatment services records reviewed. [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to provide a complete hazard vulnerability or safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect the residents from potential harm.

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to provide a complete hazard vulnerability or safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect the residents from potential harm. This has the potential to directly affect all memory care residents receiving assisted living services. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to ensure policies and procedures for assisted living with dementia care were provided to residents and the residents' legal and designated representatives for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care were provided to residents and the residents' legal and designated representatives for three of three residents (R1, R2, R3) with records reviewed. [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”