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: Oct. 29, 2024

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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/29/2024 from 08:30 AM until 05:00 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 #:	22VAC40-73-380-A
Description:	Based on record review and staff interview, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, specific personal and social information shall be obtained on the resident. EVIDENCE: 1. The record for resident 3, admitted 03/26/2024, contained a personal and social data sheet that was incomplete for the following specific information for resident 3: Most recent home address; if there any allergies; address from which received; birthplace; interests and hobbies; lifetime vocation or career or primary role; advanced directive status; and current behavioral and social functioning ? including strengths or problems. 2. The record for resident 5, admitted 07/06/2023, contained a personal and social data sheet that was incomplete for the following specific information for resident 5: Most recent home address; if there any allergies; address from which received; birthplace; interests and hobbies; lifetime vocation or career or primary role; advanced directive status; and current behavioral and social functioning ? including strengths or problems. 3. The record for resident 6, admitted 04/18/2024, contained a personal and social data sheet that was incomplete for the following specific information for resident 6: Special interests and hobbies; if there are any allergies; advanced directive status; if there is a history of mental health or intellectual disability services; current behavioral and social functioning ? including strengths or problems; and if there is a history of substance abuse. 4. An interview with staff 4 and 5 could identify the existence of personal and social data sheets that contain all required information on residents 3, 5, and 6.
Plan of Correction:	Staff to update the personal and social data sheets for Residents #3, #5, and #6. The Social Services Director to obtain and complete the Social History form upon all Resident admissions / transfers to Assisted Living level of care. A 100% audit to be conducted of all personal and social data sheets to identify any incomplete areas in order to correctly obtain any missing information and thoroughly complete the data sheets. Staff to be educated on this required data sheet documentation and completion needs. Monthly audit X3 months for all new admission data sheets then quarterly with follow-up from the Quality Assurance Committee.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) shall be reviewed and updated as needed for a significant change of a resident?s condition. EVIDENCE: 1. The record for resident 5 contained signed orders which state ?Resident is to donn palm protector to left hand to promote ROM, dexterity, prevent wounds and further contractures one time a day?, which became effective 02/09/2024. 2. The record for resident 5 contained an ISP, dated 07/06/2024; however, the ISP did not indicate that resident 5 had a daily need for the use of a palm protector to promote range of motion, dexterity, prevent wounds and further contractures. 3. An interview with staff 4 and 5 could identify the existence of an ISP where this need is addressed.
Plan of Correction:	The ISP for Resident #5 updated to include the daily use of palm protector to the left hand to promote ROM as ordered. A 100% Audit of all ISPs to be conducted in order to ensure that all physician ordered therapy aids / devices are captured and noted on the Resident?s ISP. Staff are to be educated on the required ISP documentation noted all ordered items. Monthly audit X3 months then quarterly for all new ordered therapy aids / devices along with captured documentation for follow-up from the Quality Assurance Committee.