VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Good Neighbor Village Inc.
8825 Buffin Road
Richmond, VA 23231
(804) 795-9813

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

Inspection Date: July 9, 2024

Complaint Related: No

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 07/09/2024 approximate time of 10:39a.m-12:26p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 07/02/2024 regarding allegations in the areas of administration and administrative services and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents on site wee observed at their leisure. 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 #:	22VAC40-73-440-A
Description:	Based on the review of facility records and the interview conducted the facility failed to ensure that all residents of and applicants to assisted living facilities are assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: Resident #2-Date of admission 06/20/2024 Resident # 8-Date of admission 06/21/2024 It was revealed during the review of facility records with facility staff #1 on 07/09/2024 that a Uniform Assessment Instrument (UAI) had not been conducted for resident #s 2 and 8 prior to or since admission
Plan of Correction:	FACILITY'S RESPONSE: "The Executive Director is completing the Private Pay UAI online training to be able to assess future prospective residents as well as current residents. during their annual review, or when a significant change in their condition occurs. The Executive Director has reached out to Henrico County Department of Social Services (the county in which GNV is located) to request an assessor to administer a Private Pay UAI to each of the two residents who did not receive one.
Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and the interview conducted the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #2-Date of admission 06/20/2024 Resident # 8-Date of admission 06/21/2024 It was revealed during the review of facility records with A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Angela Rodgers-Reaves Date Violation Notice Issued: 7/17/2024 facility staff #1 on 07/09/2024 that a preliminary Individualized Service Plan (ISP) had not been developed for resident #s 2 and 8 prior to or since admission
Plan of Correction:	FACILITY'S RESPONSE: " The Executive Director developed a preliminary plan of care for each of the two residents who had not had one in place. Once the UAI training is completed. the Executive Director will complete the VA ISP training so as to be able to develop ISP required for our resident in the future. If I can't find anyone else to help me develop ISPs for the two residents. I will do it once I have completed the ISP training.