Wild Fern Montessori School

8VAC20-780-270-A Complaint related: Yes

“Based on observations and interviews, the center failed to ensure areas and equipment of the center, inside and outside, shall be maintained in a safe condition. Evidence: 1. Tree branches were hanging over the fence into the play area and starting to cover some of the play equipment. 2. The branches were hanging over the fence almost touching the ground and in an area that was accessible to the children. 3. A declining tree was observed along the fence line.”

8VAC20-780-550-P

“Based on a review of eight injury report records and interview, the center did not ensure that two records contained the required information. Evidence: 1. Two minor injury reports dated 3/5/2024 and 3/20/2024 were missing the time of when the parent was notified and documentation on how parent was notified. 2. Administration acknowledged that the injury report records were incomplete.”

8VAC20-780-550-P

“Based on a review of eight injury report records and interview, the center did not ensure that two records contained the required information. Evidence: 1. Two minor injury reports dated 3/5/2024 and 3/20/2024 were missing the time of when the parent was notified and documentation on how parent was notified. 2. Administration acknowledged that the injury report records were incomplete.”

22.1-289.011-F

“Based on observation and interview, the center did not ensure that the most recent inspection findings were posted in a conspicuous place on the licensed premises. Evidence: 1. The most recent inspection report was not observed. 2. Administration acknowledged that the report was not posted.”

22.1-289.036-A

“Based on a review of records and interview, the center did not ensure that one officer of the corporation had a repeat sworn statement background check every 5 years as required. Evidence: 1. The record of officer #1 contained a sworn statement dated 8/28/2018. 2. Administration acknowledged that the repeat sworn statement had not been completed.”

8VAC20-780-245-A

“Based on a review of five staff records and interview, the center did not ensure that one staff annually completed a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of staff #1 (date of employment: 7/8/2019) contained documentation of 10 hours of annual training between 7/8/22 and 7/8/2023. 2. Administration acknowledged that staff #1 did not have 16 hours of annual training.”

22.1-289.011-F

“Based on observation and interview, the center did not ensure that the most recent inspection findings were posted in a conspicuous place on the licensed premises. Evidence: 1. The most recent inspection report was not observed. 2. Administration acknowledged that the report was not posted.”

22.1-289.036-A

“Based on a review of records and interview, the center did not ensure that one officer of the corporation had a repeat sworn statement background check every 5 years as required. Evidence: 1. The record of officer #1 contained a sworn statement dated 8/28/2018. 2. Administration acknowledged that the repeat sworn statement had not been completed.”

8VAC20-780-245-A

“Based on a review of five staff records and interview, the center did not ensure that one staff annually completed a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of staff #1 (date of employment: 7/8/2019) contained documentation of 10 hours of annual training between 7/8/22 and 7/8/2023. 2. Administration acknowledged that staff #1 did not have 16 hours of annual training.”

8VAC20-780-160-A

“Based on a review of two (2) staff records and interview, the center did not ensure to obtain documentation of a negative tuberculosis (TB) screening for one (1) staff at the time of employment and prior to coming into contact with children. The documentation must have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department. Evidence: 1. The record of staff #1 (date of employment: 6/27/2023) contained a TB screening dated 3/5/2023. 2. Administration acknowledged that the documentation had not been completed within the last 30 calendar days of the date of employment as required.”

22.1-289.035-B-4

“Based on a review of five staff records and interview, the center did not ensure to obtain the required out of state background checks for two (2) staff as required. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The record did not contain the out of state criminal name check that was required prior to the first date of employment and the out of state child abuse and neglect search request that was required by the end of the 30th day of employment. The record of staff #4 (date of employment: 3/15/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five years. The record did not contain the out of state child abuse and neglect search that is required by the end of the 30th day of employment. 2. Administration acknowledged that the out of state background checks had not been completed.”

8VAC20-770-60-C-2

“Based on a review of five (5) staff records and interview, the center did not ensure to obtain a central registry finding for one (1) staff within 30 days of employment as required. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) did not contain a central registry finding. 2. Administration acknowledged that the central registry finding was missing.”

8VAC20-780-160-C

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff had a follow up tuberculosis screening at least every two years from the date of the initial screening as required. Evidence: 1. The record of staff #3 (date of employment: 7/8/2019) contained a tuberculosis screening dated 8/9/2019. 2. Administration acknowledged that the follow up tuberculosis screening had not been completed.”

8VAC20-780-70

“Based on a review of five (5) staff records and interview, the center did not ensure that complete records were kept for two (2) staff as required. Evidence: 1. The records of staff #1 (date of employment: 8/2/2022) and staff #2 (date of employment: 3/7/2023) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. 2. The record of staff #4 (date of employment: 3/15/2022) did not contain documentation to demonstrate that the individual possessed the education required by the job position. Administration stated that the staff member had been recently promoted to a lead position and had provided transcripts that they were unable to locate during the inspection. 3. Administration acknowledged that the records were incomplete.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. Eight (8) rusted nails were observed protruding from the wooden fence on the playground. 2. Administration acknowledged that the area required maintenance.”

8VAC20-780-240-A

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment as required. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) did not contain documentation that the Virginia Department of Education-sponsored orientation course had been completed. 2. Administration acknowledged that they did not have record of the course completion for staff #1.”

8VAC20-790-600-D-2

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff who worked directly with children had within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) contained a first aid certification that expired in October of 2022. 2. The vendor acknowledged that the certification was not current.”

8VAC20-790-600-D-1

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff who worked directly with children had within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) contained a CPR certification that expired in October of 2022. 2. The vendor acknowledged that the certification was not current.”

22.1-289.035-B-4

“Based on a review of five staff records and interview, the center did not ensure to obtain the required out of state background checks for two (2) staff as required. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five (5) years. The record did not contain the out of state criminal name check that was required prior to the first date of employment and the out of state child abuse and neglect search request that was required by the end of the 30th day of employment. The record of staff #4 (date of employment: 3/15/2022) contained a sworn statement that indicated that the staff had resided outside of the state within the preceding five years. The record did not contain the out of state child abuse and neglect search that is required by the end of the 30th day of employment. 2. Administration acknowledged that the out of state background checks had not been completed.”

8VAC20-770-60-C-2

“Based on a review of five (5) staff records and interview, the center did not ensure to obtain a central registry finding for one (1) staff within 30 days of employment as required. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) did not contain a central registry finding. 2. Administration acknowledged that the central registry finding was missing.”

8VAC20-780-160-C

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff had a follow up tuberculosis screening at least every two years from the date of the initial screening as required. Evidence: 1. The record of staff #3 (date of employment: 7/8/2019) contained a tuberculosis screening dated 8/9/2019. 2. Administration acknowledged that the follow up tuberculosis screening had not been completed.”

8VAC20-780-70

“Based on a review of five (5) staff records and interview, the center did not ensure that complete records were kept for two (2) staff as required. Evidence: 1. The records of staff #1 (date of employment: 8/2/2022) and staff #2 (date of employment: 3/7/2023) did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment. 2. The record of staff #4 (date of employment: 3/15/2022) did not contain documentation to demonstrate that the individual possessed the education required by the job position. Administration stated that the staff member had been recently promoted to a lead position and had provided transcripts that they were unable to locate during the inspection. 3. Administration acknowledged that the records were incomplete.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. Eight (8) rusted nails were observed protruding from the wooden fence on the playground. 2. Administration acknowledged that the area required maintenance.”

8VAC20-780-240-A

“Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment as required. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) did not contain documentation that the Virginia Department of Education-sponsored orientation course had been completed. 2. Administration acknowledged that they did not have record of the course completion for staff #1.”

8VAC20-790-600-D-2

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff who worked directly with children had within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) contained a first aid certification that expired in October of 2022. 2. The vendor acknowledged that the certification was not current.”

8VAC20-790-600-D-1

“Based on a review of five (5) staff records and interview, the vendor did not ensure that one (1) staff who worked directly with children had within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of staff #1 (date of employment: 8/2/2022) contained a CPR certification that expired in October of 2022. 2. The vendor acknowledged that the certification was not current.”

8VAC20-790-600-D-2

“Based on a review of staff records and interview, the vendor did not ensure that all staff who work directly with children had within 90 days of the date of employment or 90 days from subsidy vendor approval current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of staff # 1 (date of employment: 8/9/2020) contained an expired first aid certification dated 7/29/2020. 2. The vendor acknowledged that the certification was not current.”

8VAC20-790-600-D-1

“Based on a review of staff records and interview, the vendor did not ensure that all staff who work directly with children had within 90 days of the date of employment or 90 days from subsidy vendor approval current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of staff # 1 (date of employment: 8/9/2020) contained an expired CPR certification dated 7/29/2020. 2. The vendor acknowledged that the certification was not current.”

8VAC20-780-550-D

“Based on a review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. The drill log was reviewed on 9/29/2022. An evacuation drill was not documented in August on 2022. 2. Administration acknowledged that a drill was not conducted in August.”

8VAC20-780-160-C

“Based on a review of five (5) staff records and interview, the center did not ensure to obtain a follow up tuberculosis screening for one (1) staff at least every two years from the date of the initial screening or testing as required. Evidence: 1. The record of staff # 1 contained a tuberculosis screening dated 5/31/2020. 2. Administration acknowledged that a follow up tuberculosis screening had not been obtained for staff #1.”

8VAC20-770-60-C-2

“Based on a review of five (5) staff records and interview, the center did not ensure to have a central registry finding for two (2) staff within 30 days of employment as required. Evidence: 1. The record of staff #2 (date of employment: 8/15/2022) did not contain a central registry finding. The record of staff #4 (date of employment: 6/14/2022) contained a central registry finding dated 7/20/2022. 2. Administration acknowledged that the findings were not obtained within the required time frame.”

8VAC20-780-550-O

“Based on a review of documentation and interview, the center did not ensure to notify parents by the end of the day of any known minor injuries as required. Evidence: 1. On 9/29/2022, three (3) injury reports were reviewed. One (1) report documented a minor injury that occurred on 09/22/2022. The parent notification date was documented as 09/23/2022. 2. Administration acknowledged that the parent was not notified on the day of occurrence.”

8VAC20-790-600-D-2

“Based on a review of staff records and interview, the vendor did not ensure that all staff who work directly with children had within 90 days of the date of employment or 90 days from subsidy vendor approval current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of staff # 1 (date of employment: 8/9/2020) contained an expired first aid certification dated 7/29/2020. 2. The vendor acknowledged that the certification was not current.”

8VAC20-790-600-D-1

“Based on a review of staff records and interview, the vendor did not ensure that all staff who work directly with children had within 90 days of the date of employment or 90 days from subsidy vendor approval current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of staff # 1 (date of employment: 8/9/2020) contained an expired CPR certification dated 7/29/2020. 2. The vendor acknowledged that the certification was not current.”

8VAC20-780-550-D

“Based on a review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. The drill log was reviewed on 9/29/2022. An evacuation drill was not documented in August on 2022. 2. Administration acknowledged that a drill was not conducted in August.”

8VAC20-780-160-C

“Based on a review of five (5) staff records and interview, the center did not ensure to obtain a follow up tuberculosis screening for one (1) staff at least every two years from the date of the initial screening or testing as required. Evidence: 1. The record of staff # 1 contained a tuberculosis screening dated 5/31/2020. 2. Administration acknowledged that a follow up tuberculosis screening had not been obtained for staff #1.”

8VAC20-770-60-C-2

“Based on a review of five (5) staff records and interview, the center did not ensure to have a central registry finding for two (2) staff within 30 days of employment as required. Evidence: 1. The record of staff #2 (date of employment: 8/15/2022) did not contain a central registry finding. The record of staff #4 (date of employment: 6/14/2022) contained a central registry finding dated 7/20/2022. 2. Administration acknowledged that the findings were not obtained within the required time frame.”

8VAC20-780-550-O

“Based on a review of documentation and interview, the center did not ensure to notify parents by the end of the day of any known minor injuries as required. Evidence: 1. On 9/29/2022, three (3) injury reports were reviewed. One (1) report documented a minor injury that occurred on 09/22/2022. The parent notification date was documented as 09/23/2022. 2. Administration acknowledged that the parent was not notified on the day of occurrence.”

8VAC20-790-600-D-1

“Based on a review of four staff records and interview, the vendor did not ensure one staff had obtained current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of staff #4 (DOH: 7/8/2019) contained a CPR certification dated 9/8/2019. 2. Administration acknowledged that the certification was expired.”

8VAC20-790-600-D-2

“Based on a review of four staff records and interview, the vendor did not ensure one staff had obtained current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of staff #4 (DOH: 7/8/2019) contained a first aid certification dated 9/8/2019. 2. Administration acknowledged that the certification was expired.”

8VAC20-770-60-C-2

“Based review of 5 staff records and interview, the center did not ensure to obtain the results of a central registry background check within 30 days of employment for one staff as required. Evidence: 1. The record of staff #2 (DOH: 11/01/2021) contained the results of a central registry background check dated 12/9/2021. 2. Administration acknowledged that it was not received within the required time frame.”

8VAC20-780-160-C

“Based on a review of four staff records and interview, the center did not ensure to obtain the results of a follow-up tuberculosis (TB) screening every two years for one staff as required. Evidence: 1. The record of staff #4 (DOH:7/8/2019) contained a TB screening dated 8/9/2019. 2. Administration acknowledged that the screening was expired.”

8VAC20-780-40-K

“Based on review of documentation and interview, the center did not ensure to develop written procedures for prevention of abusive head trauma as required. Evidence: 1. A written procedure for abusive head trauma was not observed during the inspection. 2. Administration acknowledged that the procedure had not been created.”

8VAC20-780-70

“Based on review of four staff records and interview, the center did not ensure one record contained the required information. Evidence: 1. The record of staff #3 (DOH:3/15/2022) was missing documentation that two or more references as to character and reputation as well as competency were checked before employment, documentation of orientation, information about any health problems that may interfere with fulfilling the job responsibilities, and the name, address, and telephone number of a person to be notified in an emergency. 2. Administration acknowledged that the record was incomplete.”

8VAC20-780-260-B

“Based on record review and interview, the provider did not ensure to obtain annual approval from the health department or approvals of a plan of correction, for meeting requirements for: 1. Water supply; 2. Sewage disposal system; and 3. Food service, if applicable. Evidence: 1. The last health inspection was dated 12/30/2020. 2. Administration acknowledged that they were missing a 2021 approval from VDH.”

8VAC20-780-245-L

“Based on record review and interview, the center did not ensure that there was always at least one staff member on duty who had obtained within the last three years instruction in performing the daily health observation of children. Evidence: 1. Administration was unable to provide proof of a current daily health observation training for staff during the inspection.”

22.1-289-036-B-4

“Based on a review of four staff records and interview, the center did not ensure to obtain a sex offender registry background check for one staff who resided outside of Virginia within the preceding five years a required. Evidence: 1. The record of staff #3 (DOH:3/15/2022) contained a sworn statement that indicated that the staff had resided outside of Virginia within the preceding five years. The record did not contain an out of state sex offender name check for the state listed. 2. Administration acknowledged that the out of state sex offender background check had not been completed.”

8VAC20-780-260-A

“Based on record review and interview, the center did not ensure to provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: 1. The last fire inspection was dated 11/25/2020. 2. Administration acknowledged that they were missing an annual inspection from 2021.”

8VAC20-790-600-D-1

“Based on a review of four staff records and interview, the vendor did not ensure one staff had obtained current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of staff #4 (DOH: 7/8/2019) contained a CPR certification dated 9/8/2019. 2. Administration acknowledged that the certification was expired.”

8VAC20-790-600-D-2

“Based on a review of four staff records and interview, the vendor did not ensure one staff had obtained current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of staff #4 (DOH: 7/8/2019) contained a first aid certification dated 9/8/2019. 2. Administration acknowledged that the certification was expired.”

8VAC20-770-60-C-2

“Based review of 5 staff records and interview, the center did not ensure to obtain the results of a central registry background check within 30 days of employment for one staff as required. Evidence: 1. The record of staff #2 (DOH: 11/01/2021) contained the results of a central registry background check dated 12/9/2021. 2. Administration acknowledged that it was not received within the required time frame.”

8VAC20-780-160-C

“Based on a review of four staff records and interview, the center did not ensure to obtain the results of a follow-up tuberculosis (TB) screening every two years for one staff as required. Evidence: 1. The record of staff #4 (DOH:7/8/2019) contained a TB screening dated 8/9/2019. 2. Administration acknowledged that the screening was expired.”

8VAC20-780-40-K

“Based on review of documentation and interview, the center did not ensure to develop written procedures for prevention of abusive head trauma as required. Evidence: 1. A written procedure for abusive head trauma was not observed during the inspection. 2. Administration acknowledged that the procedure had not been created.”

8VAC20-780-70

“Based on review of four staff records and interview, the center did not ensure one record contained the required information. Evidence: 1. The record of staff #3 (DOH:3/15/2022) was missing documentation that two or more references as to character and reputation as well as competency were checked before employment, documentation of orientation, information about any health problems that may interfere with fulfilling the job responsibilities, and the name, address, and telephone number of a person to be notified in an emergency. 2. Administration acknowledged that the record was incomplete.”

8VAC20-780-260-B

“Based on record review and interview, the provider did not ensure to obtain annual approval from the health department or approvals of a plan of correction, for meeting requirements for: 1. Water supply; 2. Sewage disposal system; and 3. Food service, if applicable. Evidence: 1. The last health inspection was dated 12/30/2020. 2. Administration acknowledged that they were missing a 2021 approval from VDH.”

8VAC20-780-245-L

“Based on record review and interview, the center did not ensure that there was always at least one staff member on duty who had obtained within the last three years instruction in performing the daily health observation of children. Evidence: 1. Administration was unable to provide proof of a current daily health observation training for staff during the inspection.”

22.1-289-036-B-4

“Based on a review of four staff records and interview, the center did not ensure to obtain a sex offender registry background check for one staff who resided outside of Virginia within the preceding five years a required. Evidence: 1. The record of staff #3 (DOH:3/15/2022) contained a sworn statement that indicated that the staff had resided outside of Virginia within the preceding five years. The record did not contain an out of state sex offender name check for the state listed. 2. Administration acknowledged that the out of state sex offender background check had not been completed.”

8VAC20-780-260-A

“Based on record review and interview, the center did not ensure to provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: 1. The last fire inspection was dated 11/25/2020. 2. Administration acknowledged that they were missing an annual inspection from 2021.”

22VAC40-665-580-B

“Based on record review and interview, the vendor did not ensure that all staff who work directly with children complete the Virginia Preservice Training for Child Care within 90 days of employment as required. Evidence: 1. The record of staff #3 (DOH: 1/28/2021) contained documentation of the Virginia Preservice Training for Child Care Staff dated 08/02/2021. 2. Administration acknowledged that the training had not been completed within 90 days of employment.”

63.2(17)-1720.1-B-4

“Based on record review and interview, the center did not ensure to obtain the results of a sex offender registry check and the child abuse and neglect registry or equivalent registry within the required time frame from any state in which the individual had resided in the preceding five years for one staff member. Evidence: 1. The record of staff #1 (DOH: 1/30/2021) contained a sworn statement that indicated that the staff member had resided outside of the state of Virginia within the past 5 years. The record did not contain the results of an out of state sex offender registry check prior to hire as required and the results of an out of state child abuse and neglect search within 30 days. 2. Administration acknowledged that the background checks had not been initiated.”

22VAC40-665-580-B

“Based on record review and interview, the vendor did not ensure that all staff who work directly with children complete the Virginia Preservice Training for Child Care within 90 days of employment as required. Evidence: 1. The record of staff #3 (DOH: 1/28/2021) contained documentation of the Virginia Preservice Training for Child Care Staff dated 08/02/2021. 2. Administration acknowledged that the training had not been completed within 90 days of employment.”

63.2(17)-1720.1-B-4

“Based on record review and interview, the center did not ensure to obtain the results of a sex offender registry check and the child abuse and neglect registry or equivalent registry within the required time frame from any state in which the individual had resided in the preceding five years for one staff member. Evidence: 1. The record of staff #1 (DOH: 1/30/2021) contained a sworn statement that indicated that the staff member had resided outside of the state of Virginia within the past 5 years. The record did not contain the results of an out of state sex offender registry check prior to hire as required and the results of an out of state child abuse and neglect search within 30 days. 2. Administration acknowledged that the background checks had not been initiated.”