VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Kings Grant Retirement Community-Craig Assisted Living
350 Kings Way Rd.
Martinsville, VA 24112-6631
(276) 634-1000

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Aug. 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 08/23/2023 from 09:00 AM until 04:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility that the direct care or companion services provided by private duty personnel to meet identified needs shall be reflected on the resident?s individualized service plan (ISP). EVIDENCE: 1. The record for resident 3 contains documentation that the resident has sitter services provided by Collateral 2. 2. Interview with staff persons 5 and 6 revealed that the sitters from Collateral 2 provide companion services to the resident and that the sitters also take the resident to appointments; however, this information is not identified on the resident?s ISP dated 06/08/2023.
Plan of Correction:	Per King?s Grant policy, all Sitter / Companions do not provide any form of direct care within the licensed areas. Within licensed areas, the Sitters can only provide Companionship and transportation as needed. Resident #3 -documentation to be noted of resident Sitter / Companion transport services on the ISP. 100% Audit conducted to identify all Sitter Companions within licensed areas with their ISP to identify their associated Sitter Companions noting that the identified Resident has a Sitter Companion that does not provide any direct care- only companion / transport services as identified per KG policy. Staff educated on this required ISP documentation. Monthly audit x3 months then quarterly with follow-up from the Quality Assurance Committee.
Standard #:	22VAC40-73-325-C
Description:	Based on record review, the facility failed to ensure that if a resident who meets the criteria for assisted living care falls, there must be documentation that shows an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. EVIDENCE: 1. The uniform assessment instrument for resident 2, dated 03/10/2023, indicates that resident 2 is appropriate for assisted living level of care. 2. The progress notes for resident 2 contain documentation of falls that occurred on 06/13/2023 and 07/03/2023. 3. The record for resident 2 contained MORSE Fall assessments dated 06/13/2023 and 07/03/2023; however, that documentation did not contain an analysis of the circumstances of the fall nor interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	Resident #2 Fall Risk Analysis and Interventions to be added to ISP. 100% Audit for all AL Licensed areas for any Resident rated as High Fall Risk on assessment and any recent fall within the last 3 months to document the analysis of the fall circumstances on the associated incident report and to initiate interventions for fall risk reduction to be noted on the ISP. Staff educated on required documentation. Monthly audit x3 months then quarterly with follow-up from the Quality Assurance Committee.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure that a review and update of the Individualized Service Plan (ISP) occurred at least once every 12 months and as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 2 contains MORSE Fall assessments dated 06/13/2023 and 07/03/2023, which indicate that the resident is at a high risk for falls; however, the ISP for resident 2, dated 03/10/2023, does not indicate a high fall risk as an identified need for the resident. 2. The record for resident 3 contains MORSE Fall assessments dated 07/16/2023 and 08/17/2023, which indicate that the resident is at a high risk for falls; however, the ISP for resident 3, dated 06/08/2023, does not indicate that the resident is a high fall risk. 3. The record for resident 5 contains MORSE Fall assessments dated 5/17/2023 and 7/17/2023, which indicate that the resident is at a high risk for falls; however, the Individualized Service Plan (ISP) for resident 5, dated 01/12/2023, does not indicate a high fall risk as an identified need for the resident. 4. The record for resident 6 contains MORSE Fall assessments dated 5/5/2023, 5/31/2023, and 7/12/2023, which indicate that the resident is at a high risk for falls; however, the ISP for resident 6, dated 07/22/2023, does not indicate a high fall risk as an identified need for the resident. 5. The record for resident 7 contains MORSE Fall assessments dated 6/18/2023, 7/5/2023, and 7/12/2023, which indicate that the resident is at a high risk for falls; however, the ISP for resident 7, dated 12/08/2022, does not indicate a high fall risk as an identified need for the resident.
Plan of Correction:	Residents #2, #3, #5, #6, and #7 ? ISP corrected to indicate a high fall risk. 100% Audit for all AL Licensed areas for any Resident rated as High Fall Risk on assessment and any recent fall within the last 3 months to document the High Fall Risk on their ISP and to initiate interventions for fall risk reduction to also be noted on the ISP. Staff educated on required documentation. Monthly audit x3 months then quarterly with follow-up from the Quality Assurance Committee.