University Montessori School, Inc.

8VAC20-780-245-M

“Documentation of training shall be kept by the center in a manner that allows for identification by individual staff member, is considered part of the staff member’s record. The records for three staff did not contain documentation of annual training.”

Rule 8VAC20-780-245-M.

8VAC20-780-510-F

“The medication authorization shall be available to staff during the entire time it is effective. One medication did not have a medication authorization form.”

Rule 8VAC20-780-510-F.

8VAC20-780-550-P

“The center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence and include the following: Date and time of injury; Name of injured child; Type and circumstance of the injury; Staff present and treatment; Date and time when parents were notified; Any future action to prevent recurrence of the injury; Staff and parent signatures or two staff signatures; and Documentation on how parent was notified. An injury report did not contain signatures and time the parent was notified.”

Rule 8VAC20-780-550-P.

22.1-289.036-B-3

“The center must request a search of the central registry prior to the any agents of the facility first day. Agent #1’s has been a agent for the center for a year and the center does not have a central registry background check.”

Rule 22.1-289.036-B-3.

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Staff #5 has no documentation of training hours for 2024.”

Rule 8VAC20-780-245-A.

8VAC20-780-560-G

“REPEAT VIOLATIONS When food is brought from home the food container must be clearly dated. Four out of seven lunch boxes viewed were not labeled.”

Rule 8VAC20-780-560-G.

8VAC20-780-150-B

“Each report shall include the date of the physical examination and dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. Child 1 and child 2’s immunizations and physical examinations were not signed.”

Rule 8VAC20-780-150-B.

8VAC20-780-40-E

“The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with these standards, the center’s own policies and procedures that are required by these standards. The center’s medication policy is in part: The UMS staff checks medication lock boxes on a monthly basis for expired medications and/or authorizations. The center had an emergency medication that expired February 2025.”

Rule 8VAC20-780-40-E.

8VAC20-780-510-P

“When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. An emergency medication for child 6 expired February 2025 and the parents were not notified to pick up the medication.”

Rule 8VAC20-780-510-P.

8VAC20-780-560-G

“When food is brought from home the food container shall be sealed and clearly dated and labeled in a way that identifies the owner. None of the food containers were dated and out of six checked four did not identify the owner.”

Rule 8VAC20-780-560-G.

Based on record review, the center failed to ensure each staff member submitted documentation of a negative tuberculosis (TB) screening that was completed within the last 30 days of the date of employment.

“Evidence: Staff 4’s tuberculosis screening was completed over a year prior to hire.”

Rule 8VAC20-780-160-A.

Based on record review, the center failed to ensure each staff member submit a follow-up tuberculosis (TB) screening at least every two years from the date of the previous test or screening.

“Evidence: Staff 1’s TB screening expired 06/24/23.”

Rule 8VAC20-780-160-C.

Based on record review and interview, the center failed to obtain a written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.

“Evidence: Three children’s food allergies were posted and listed in their records. The administrator stated the center does not have a written care plan from a physician regarding the food the children are allergic to for the three children.”

Rule 8VAC20-780-60-A-8.

Based on observation and interview, the center failed to ensure that the violation notice and summary for the last inspection was posted in a conspicuous place on the licensed premises.

“Evidence: 1. The inspection violation notice posted outside the Primary Classroom was dated March 2023. The last inspection was completed on 09/12/2023. 2. Administration verified that the inspection violation notice from 9/12/2023 had not been posted.”

Rule 22.1-289.011-F.

Based on review of staff files, the center failed to ensure that required background checks were updated every five years.

“Evidence: 1. The national fingerprint background check for Staff #2 was last dated 01/17/2019. A new background check was required by 01/17/2024. 2. Administration verified that an updated national fingerprint background check had not been completed for Staff #2.”

Rule 22.1-289.035-A.

Based on review of staff records, the center failed to ensure that tuberculosis documentation was obtained within the last 30 calendar days of the date of employment.

“Evidence: Staff #1 date of rehire was 10/09/2023. The tuberculosis screening in Staff #1’s file was dated 06/29/2023.”

Rule 8VAC20-780-160-A.

Based on observation, the center failed to ensure that all equipment shall be maintained in a safe and operable condition.

“Evidence: There is peeling paint on the play structure that is on the playground. The peeling paint is on the landing of the structure.”

Rule 8VAC20-780-270-A.

Based on observation and interview, the center failed to ensure that a current written list of all children’s allergies, sensitivities, and dietary restrictions shall be kept in each room or area where children are present.

“Evidence: 1. There was not an allergy list posted in the upstairs Primary Classroom. 2. Staff verified that there was not an allergy list posted in the classroom.”

Rule 8VAC20-780-40-M.

Based on record review and interview, the center failed to obtain fingerprint results prior to the first day of employment.

“Evidence: 1. The record for staff 2 documents the first day of employment as 8/28/23. The fingerprint results are dated 9/13/23. 2. Staff 6 verified the date of employment and date of fingerprint results.”

Rule 22.1-289.035-B-2.

Based on interviews, the center failed to obtain fingerprint background checks prior to the first day of service for two out of three agents of the center.

“Evidence: 1. Staff 6 was unable to provide fingerprint results for board officer 1. Staff 6 stated board officer 1 started as a board officer on 9/23/21. 2. Board officer 3’s fingerprint results are dated 11/5/21. 3. Staff 6 stated board officer 3 started as a board officer on 9/23/21.”

Rule 22.1-289.036-B-2.

Based on record review and interview, the center failed to have an agent of the center sign a sworn disclosure statement prior to the first day of service and have a completed central registry record check by the end of the 30th day of service.

“Evidence: 1. Staff 6 stated board officer 1 has not completed a sworn disclosure statement and has not completed a central registry record check. 2. Staff 6 stated board officer 1 started as a board officer on 9/23/21. 3. Board officer 3 completed the sworn statement on 11/4/21 and the central registry findings were dated 12/28/21. 4. Staff 6 stated board officer 3 started as a board officer on 9/23/21.”

Rule 8VAC20-770-40-D-1-a.

Based on record review and interview, the center failed to ensure two out of five staff met one of the requirements to be a program leader.

Rule 8VAC20-780-210-A.

Based on observation, the center failed to ensure hazardous substances such as cleaning materials are kept in a locked place using a safe locking method that prevents access by children.

“Evidence: 1. In the upstairs classroom an unlabeled bottle of Steramine sanitizer was on an open shelf out of reach of children. Staff 6 verified the bottle contained Steramine. 2. In the downstairs classroom a spray bottle of Goo Gone was on an open shelf out of reach of children.”

Rule 8VAC20-780-280-B.

Based on observation, the center failed to keep a hazardous substance that was not in its original container in a container that is clearly labeled indicating its contents.

“Evidence: 1. In the upstairs classroom a clear spray bottle was on an open shelf with no label of its contents. 2. Staff 6 stated the bottle contained the sanitizer Steramine and should have been labeled.”

Rule 8VAC20-780-280-G.

Based on interview, the center failed to maintain a medication authorization for two medications at the center.

“Evidence; 1. In the upstairs classroom a tube of Cortizone and itch relief cream was on a shelf. 2. Staff 6 stated both creams belong to children in care and the center did not have medication authorizations for either medication.”

Rule 8VAC20-780-510-F.

Based on observation and interview, the center failed to label medication with the dosage amount and times to be given.

“Evidence: 1. In the upstairs classroom a tube of Cortizone and Itch relief ointment was found. Neither product was labeled with the dosage and time to be given. 2. Staff 6 verified both creams were for children in care.”

Rule 8VAC20-780-510-G.

Based on observation, the center failed to keep medication in a locked location using a safe locking method that prevents access by children.

“Evidence: 1. In the upstairs classroom, on a high shelf, was a tube of Cortizone and itch relief cream. 2. Staff 6 verified both medications belonged to children in care.”

Rule 8VAC20-780-510-L.

Based on interview, the center did not keep a record of medication given to children.

“Evidence: A tube of Cortizone and Itch Relief Cream was found in the upstairs classroom. Staff 6 verified the over-the-counter medications were for children and both had been administered a few times. No documentation had been completed for either medication.”

Rule 8VAC20-780-510-N.

Based on record review and observation, the center failed to ensure at least one staff in each classroom or area where children are present has a current certification in CPR & first aid.

“Evidence: 1. Staff 2 was alone outside with children. The record for staff 2 did not contain a certification in CPR & first aid. 2. Staff 4 was alone with children during nap in the main space downstairs. The record for staff 4 did not contain a certification in CPR & first aid. 3. Staff 6 verified staff 2 and staff 4 do not have certification in CPR & first aid.”

Rule 8VAC20-780-530-A.

Based on record review and interview, the center failed to practice lockdown procedures at least annually.

“Evidence: 1. The documentation of emergency drills were reviewed during the inspection on 03/20/2023. No documentation of a lockdown drill being completed was documented for 2022. 2. The director confirmed a lockdown drill was not completed for 2022.”

Rule 8VAC20-780-550-F.

Based on record review and interview, the center failed to obtain and document at least two references as to the character and reputation as well as competency before employment for the two staff records reviewed .

“Evidence: 1. The record for staff 1 documents the hire date as 8/3/22. There was no documentation in the file of references being completed. 2. The record for staff 2 documents the hire date as 6/16/22. The record contained documentation stating references were attempted but unsuccessful. 3. The director was unable to find documentation of references being completed for staff 1 or staff 2.”

Rule 8VAC20-780-70.