VIRGINIA DEPARTMENT OF SOCIAL SERVICES

St. Mary's Woods
1257 Marywood Lane
Richmond, VA 23229
(804) 741-8624

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: June 7, 2024

Complaint Related: No

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: On 06/04/2024 approximate time 10:00a.m ? 3:42p.m. On 06/07/2024 approximate time 9:50a.m ? 3:00p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection Number of residents present at the facility at the beginning of the inspection: 128 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: An observation of a medication administration pass and the lunch time meal was conducted on 06/07/2024. Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that within the 30 days preceding admission, the physical examination report on file at the assisted living facility contained all of the required elements. Evidence: Resident #4 Date of admission 01/15/2024 The facility documentation reviewed with the facility Administrator and staff #1 and identified by the staff as the results of a risk assessment documenting the absence of tuberculosis in a communicable form for resident #4 is dated 01/22/2024 seven days after the resident?s documented date of admission.
Plan of Correction:	FACILITY'S RESPONSE: "Corrective action ? Chest x-ray dated 1/18/2024 for resident #4 admitted on 1/24/2024 received on 1/22/2024; within 30 days preceding admission missing ?free of tuberculosis? finding. How to identify other residents affected ? The DON or designee will audit all resident charts to ensure any chest x-rays include a statement that the residents is ?free of tuberculosis.? Systemic changes ? The DON or designee will review required documents prior to admission to ensure a risk assessment or chest x-ray documenting the absence of tuberculosis in a communicable form. Monitoring ? The Administrator of designee will audit 25% of new admission documents for the next quarter. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate."
Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care is developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #6 Documented date of admission 04/27/2024 The facility assessed resident # 6 on 05/10/2024 as needing human help and supervision with bathing, toileting and transferring. Resident #8 Documented date of admission 05/08/2024 The facility assessed resident # 6 on 04/30/2024 as needing human help and supervision with bathing, toileting and transferring. During staff interviews and the review of facility records while onsite at the facility on 06/04, 07/2024, the facility did not submit for the inspector?s review documented evidence that a preliminary ISP (Individualized Service Plan) had been developed for resident #s 6 and 8. During interviews facility staff #1 stated that while these residents have been assessed as needing assistance with some of their activities of daily living (ADLs) the facility does not provide assistance with these services as the residents can perform these tasks without assistance.
Plan of Correction:	FACILITY'S RESPONSE: "Corrective action-The Administrator, Director of Nursing and designated certified Universal Assessment Instrument (UAI) assessors will update their VDSS UAI training certification to ensure classification of those Residential Living ?Independent Living Status? residents reflects regulation 22VAC40-73-450.B. The UAIs for residents #s 6 and 8 have been updated to accurately reflect their needs. Based on the updated UAIs, no ISP is required as residents #6 and8 are assessed as capable of maintaining themselves in an independent living status. How to identify other residents affected ? The DON or designee will review all residential living resident charts to ensure an ISP is in place, if required, based on the UAI. Systemic changes ?The DON or designee will review required documents prior to admission to ensure an ISP is in place, if required, based on the UAI. Monitoring -The Administrator of designee will audit 25% of new admission documents for the next quarter. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that residents Individualized service plans (ISP) were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Resident #5 Documented date of admission 10/26/2020 During staff interviews and the review of facility records while onsite at the facility on 06/04, 07/2024, the facility did not submit for the inspector?s review documented evidence that an updated ISP (Individualized Service Plan) had been developed for resident #5. During interviews facility staff #1 stated that while the resident has been assessed as needing assistance with some activities of daily living (ADLs) the facility does not provide assistance with these services as the resident can do for themselves.
Plan of Correction:	FACILITY'S RESPONSE: "Corrective action ?The Administrator, Director of Nursing and designated certified Universal Assessment Instrument (UAI) assessors will update their VDSS UAI training certification to ensure classification of those Residential Living ?Independent Living Status? residents reflects regulation 22VAC40-73-450.B. Based on the updated UAIs, no ISP is required as resident #5 is assessed as capable of maintaining themselves in an independent living status How to identify other residents affected ? The DON or designee will review all residential living resident charts to ensure an ISP is in place, if required, based on the UAI. Systemic changes ?The DON or designee will review required documents prior to admission to ensure an ISP is in place, as appropriate, based on the UAI. Monitoring - The Administrator of designee will audit 25% of new admission documents for the next quarter. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate."