VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of Hope
13700 N. Gayton Road
Richmond, VA 23233
(804) 360-1960

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: June 3, 2022

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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

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: 06/03/2022 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: 80 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: 10 Number of interviews conducted with residents: Interviews conducted during the building tour with residents, staff , and others. Number of interviews conducted with staff: 03 Observations by licensing inspector: Medication pass and activities observation Additional Comments/Discussion: N/A 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti. Colson @dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1180-A
Description:	VIOLATION: Based upon observation made during the building tour, the facility failed to take special environmental precaution to eliminate hazards for the safety and wellbeing of the residents in the secure unit. EVIDENCE: The secure unit had a metal typewriter sitting on the unit?s floor accessible for the residents in care as a memory activity. The facility failed to secure the typewriter to the floor or a desk as a safety measure.
Plan of Correction:	The metal typewriter was immediately removed on 6/03/22 from facility. The Assisted Living staff will be educated on those potential environmental hazards which should be prohibited from use in a memory care center. The Memory Care Director of Nursing, or designee will inspect the resident rooms and common areas in the unit daily to identify any prohibited items. If any prohibited items are discovered duringthe nursing inspections they will be removed from the unit immediately. The findings of the unit inspections will be discussed in the quarter QA Committee meeting.
Standard #:	22VAC40-73-260-A
Description:	VIOLATION: Based upon the record review, the facility failed to maintain current certification for CPR/AED for each employee. EVIDENCE: Employee #8 and employee #6 failed to have a current certification for CPR/ AED.
Plan of Correction:	Employee #8 immediately brought in a current signed CPR card. Employee #6 obtained CPR certification on 6/20/22. Signed CPR card presented to facility. The Business Office Manager, or designee will review each employee file for the presence of a completed CPR card. The facility Administrator, or designee will review 10% of the new hire employment files each quarter to ensure compliance with maintaining current certification for CPR/AED for each employee. The .findings of the employee files will be reviewed by the quarterly QA Committee .
Standard #:	22VAC40-73-870-A
Description:	VIOLATION: Based upon the building tour observation, the facility failed to maintain the interior building. EVIDENCE: A portion of the wall located in Room #116 had a medium size hole that was located behind the resident?s recliner chair.
Plan of Correction:	The medium size hole in room, #116 located behind the resident's recliner chair was repaired on 6/03/2022. The Maintenance Department staff inspected all the room's on Assisted Living on 6/03/2022 and found no other rooms with holes in the walls. The Assisted Living Director of Nursing or designee will review with staff of the need to immediately report any defects in the physical plant, whether in a resident room or any of the common areas. The Maintenance Department staff will inspect the Assisted Living rooms weekly for 4 weeks, and monthly thereafter to identify the presence of any defects in the physical plant. The Maintenance Department will report their room inspection findings at the quarterly QA Committee meetings.