VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Generations Crossing
3765 Taylor Spring Lane
Rockingham, VA 22801
(540) 434-4901

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Sept. 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 63.2 GENERAL PROVISIONS 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 CRIMINAL PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Answered questions and discussed the following: 1. All areas of 560.C must be reviewed with all staff at least once every six months. Documentation of this training should be signed and dated by each staff when completed. 2. Discussed what constitutes a major incident - any incident that negatively affects or threatens the life, health and safety of a resident. Incidents that result in 911 being called must be reported to the licensing office within 24 hours and a full report sent within seven days. 3. Reviewed the standards for plans of care and discussed the model form versus the facility form. 4. The drug reference book must be replaced by the end of the year as it is a 2020 book and is only good for two years.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/8/2022 from approximately 8:00 am to 3:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 3 + selected sections of 6 additional staff records Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication administration, meals and activities Additional Comments/Discussion: An interview was also conducted with one family member. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-61-160-A-1
Description:	Based upon documentation and interviews, the facility failed to ensure one of nine staff records reviewed maintained current certification in first aid. Evidence: 1. The most current first aid certificate on file for staff 3 expired 8/5/2022. 2. On 9/8/2022, the licensing inspector (LI) interviewed the executive director (ED) and nurse coordinator who both stated staff 3 did not have current first aid certification.
Plan of Correction:	On 9/8/22, the ED contacted a local first aid instructor to schedule a First Aid class for staff 3. Full compliance will be met by 9/23/22. Moving forward, the ED added First Aid training to the staff check-list which is reviewed each month, to ensure no lapse in coverage will occur.
Standard #:	22VAC40-61-560-C
Description:	Based upon record reviews and interviews, the facility failed to ensure three of the three staff records reviewed had documentation of six month reviews for resident emergencies. Evidence: 1. Resident emergency reviews were last completed on 1/3/2020 for staff 1, 12/17/2021 for staff 2, and 12/16/2022 for staff 3. 2. On 9/8/2022, the LI interviewed the ED and nurse coordinator and both stated the six month reviews had not been completed.
Plan of Correction:	Resident Emergencies will be reviewed with each staff member by the Nurse Coordinator by 9/23/22. In order to ensure compliance with a six-month review of resident emergencies moving forward, the ED put this review on the staff meeting agenda for every January and July.