VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Wybe & Marietje Kroontje Health Care Center
1000 Litton Lane
Blacksburg, VA 24060
(540) 953-3200

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: April 24, 2024 and April 25, 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/24/2024 10:22am to 3:15pm and 04/25/2024 10:04am to 2:39pm 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: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. 1. The date of hire for staff #3 was 08/09/2010. 2. The most recent TB risk assessment observed in the record for staff #3 was dated 08/09/2022.
Plan of Correction:	100% audit of all employees to ensure TB screening is completed and ensure each individual is free of TB in a communicable form. Employee #3 TB risk assessment form was completed and now in compliance. The Staff Education Director / designee will ensure all staff complete their TB screening annually to ensure each individual is free of TB in a communicable form. The Staff Education Director / designee will monitor all TB assessments and Administrator to be notified of any discrepancies. The expectation of 100% compliance each month for three months with any negative findings reported to QAA. [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during a tour of the building, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. 1. In resident room #118, the hot water reached a temperature of only 89 degrees Fahrenheit.
Plan of Correction:	The hot water issue was corrected in 118 and now consistently reads above 105 degrees and below 120 degrees Fahrenheit per regulations. The facility will be maintain hot water between 105 and 120 degrees Fahrenheit for all residents. The Director of Housekeeping / designee will make rounds and supervise the staff to ensure the facility is maintaining proper water temperature. The Director of Housekeeping / designee will do monthly temperature checks and report to QAA on a monthly basis to ensure compliance for the next three months. A 100% compliance rating will be required. Any issues found to be fixed by Maintenance / designee. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. 1. Upon entering the assisted living portion of the facility, there was a large, darkened area on the carpeting in front of the double doors.
Plan of Correction:	The large, darkened area on the carpeting in front of the double doors was replaced. The facility flooring will be kept clean and free of rubbish for all residents. The Director of Housekeeping / designee will make rounds and supervise the staff to ensure the facility floor remains clean and free of stains. Facility walk-thru will be completed and reported to QAA on a monthly basis for the next three months to ensure compliance. A 100% compliance rating will be acceptable. [SIC]
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. 1. The date of hire for staff #6 was 08/07/2023. 2. The criminal history record report for staff #6 was requested by the facility on 08/03/2023. 3. At the time of inspection on 04/24/2024, the requested report had not yet been provided to the facility and there was no documentation of any follow up that had occurred. 4. Per 22VAC40-90-10, "Criminal history record report" means either the criminal record clearance or the criminal history record issued by the Central Criminal Records Exchange, Department of State Police.
Plan of Correction:	The criminal history report was completed for staff member #6 and the results were ?no identifiable records?. 100% audit completed to ensure all other employees are in compliance. The Human Resources Generalist / designee will check all potential employees and receive their completed background check before beginning employment. The Director of Human Resources / designee will monitor all background checks and Administrator to be notified of any discrepancies. The expectation of 100% compliance each month for three months with any negative findings reported to QAA. [SIC]