VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Kingston Center
428 Cecil D. Quillen Drive
Thomas Village
Duffield, VA 24244
(276) 431-4200

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: March 31, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 03/21/2021 and concluded on 04/05/2021. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on review of documentation and incident reports, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. According to staff interviews resident # 1 had suicidal ideations and a plan to attempt suicide on 03/28/2021. Resident # 1 was sent to the hospital for a mental health evaluation and was placed in a mental health facility. 2. The licensing inspector did not receive an incident report regarding resident # 1 within 24 hours of the occurrence.
Plan of Correction:	In the future, Director of Nursing will send an incident report to the regional licensing office within 24 hours of an occurrence of any major incident that has negatively affected or threatens the life, health, safety or welfare of and resident. [sic]