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: May 10, 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: Monitoring Date(s) of inspection 05/10/2022 Start time: 9:50am End Time:4:22pm the licensing inspector was on-site at the facility for the inspection: Page 1 of 2 VIRGINIA DEPARTMENT OF SOCIAL SERVICES DIVISION OF LICENSING PROGRAMS INSPECTION SUMMARY (ASSISTED LIVING FACILITY) Facility Name: Kingston Inspection Date: 05/10/2022 File #:110397 DBA: Inspection End Date: 5/10/2022 ___________________________________________________________________________________________ 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 Crystal B. Mullins, Licensing Inspector at 276-6080-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Choose an item. A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Crystal B.Mullins Date Inspection Summary Issued: 6/5/2022

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observations made during the tour of the building, the facility failed to have a listing of all staff who have current certification in first aid or CPR posted so the information is available to staff at all times. EVIDENCE: 1. During the 05/10/2022 inspection, the LI did not see the posted list of all staff certified in CPR and first aid. Staff #1 confirmed there was not posting in the facility.
Plan of Correction:	A listing of all staff who have current certification in first aid or CPR has been posted so that the information is always available to staff. In the future, the Director of Nursing will monitor the listing, and update as needed. [sic]
Standard #:	22VAC40-73-350-B
Description:	Based on observations made during resident record review, the facility failed to ascertain, prior to admission whether a potential resident is a registered sex offender and this shall be documented in the resident?s record that it was ascertained and the date the information was obtained. EVIDENCE: 1. Resident #16 was admitted to the facility on 12/09/2021. 2. Resident #16 did not have the documented sex offender register check in her file
Plan of Correction:	A sex offender registry check was performed for resident #16 and placed in their chart. In the future, the Director of Nursing will ensure that all admissions will have a sex offender registry check performed prior to, or the day of admission. The document will be available in the resident chart for review. 05/12/2022 [sic]
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during the tour of the building, the facility failed to have a written schedule of activities posted. EVIDENCE: 1. During the 05/10/2022 inspection, the LI did not see a written schedule of activities posted. Staff #17 stated it had been taken down in preparation for painting
Plan of Correction:	The written schedule of activities has been posted. In the future, the Administrator will ensure that the activity schedule is always posted. [sic]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the building, the facility failed to have menu for meals and snacks for the current week dated and posted in an area conspicuous to residents. EVIDENCE: 1. During the 05/10/2022 inspection, the LI did not see a menu posted. Staff #17 stated it had been taken down in preparation for painting.
Plan of Correction:	The menu for meals and snacks for the current week is dated and posted in a conspicuous area to residents. In the future, the Administrator will ensure that this is updated weekly. [sic]
Standard #:	22VAC40-73-620-B
Description:	Based on documentation review, the facility failed to have the oversight of special diets signed by the dietitian or nutritionist. EVIDNECE: 1. The facility presented the LI with the oversight of special diets dated 12/17/2021. There was no signature of the person completing the oversight.
Plan of Correction:	The Registered Dietician signed the oversight (that was completed on 12-17-2021) on her most recent oversight visit on06-03-2022. In the future, the Administrator will ensure that prior to the Registered Dietician leaving the facility, all oversight paperwork is signed. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the audit of the medication cart, the facility failed to ensure all mregistered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident #17 is prescribed Solstar 100 units inject Subcutaneous; eight units at bedtime. There was no open date labeled on this medication in the C-wing medication cart.edications hall be administered consistent with the standards of practice outlined in the current
Plan of Correction:	An open date was labeled on this medication. In the future, the Director of Nursing will do bi-weekly monitoring of the medication carts to ensure that all opened medication has an open date. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior and exterior of all buildings in good repair and keep it clean and free of rubbish. EVIDENCE: 1. Room B9 has floor tiles that have holes at the edge of the bed located next to the window. 2. Room C4 has floor tiles around the toilet which were stained and had chipped areas with visible caulking. The baseboard has been removed from the back and side walls and was found laying under the sink in Room C4. The toilet seat was loose. 3. Room C5 bathroom toilet seat was loose. 4. Room B9?s bathroom door at the wall is missing baseboard and corner of wall is scuffed missing paint. The bathroom doorframe is rusted and scraped from floor up to about four and a half feet along the frame. 5. The baseboard outside of Room B9 beside of the door has pulled away from the wall. 6. The bathroom walls and the door frame in Room A4 is scuffed and scraped and in need of paint. 7. The door leading to the courtyard on C-hall at the bending machines was black and had dirt and scrap/scratch marks. 8. The floor tiles around the floor drain in the bathroom were busted and missing leaving a divit with no tile approximately four inches wide and four inches long; the flor was dirty and stained around the base of the toilet in Room C11.
Plan of Correction:	Room B9 the flooring is being replaced. Room C4 the floor tiles around the toilet is being replaced. New baseboard is being installed. The toilet seat has been tightened. Room C5 the toilet seat has been tightened. Room B9?s bathroom door at the wall baseboard is being replaced, and the corner wall has been re-painted. The bathroom doorframe has been re-painted. New baseboard outside of B9 is being installed. The bathroom walls and the door frame in room A4 has been re-painted. The door leading to the courtyard has been re-painted. The floor tiles around the floor drain in room C11 are being replaced. In the future, housekeeping will monitor for any interior or exterior areas that need repair or cleaning. [sic]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during the tour of the building, the facility failed to be free from stale, foul, and musty odors. EVIDENCE: 1. The bathroom in C4 had a strong urine odor. 2. The bathroom in C20 had a strong odor of urine.
Plan of Correction:	The bathroom in C4 has been cleaned and odors removed. The bathroom in C20 has been cleaned and odors removed. In the future, housekeeping will monitor rooms to ensure that they are free from stale, foul and musty odors. [sic]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to keep clean and in good repair all furnishings, fixtures, and equipment including furniture, window coverings, sinks, toilets, bathtubs and showers except those owned by a resident. EVIDENCE: 1. Room B9 has a heating and air system under the window. This unit is inoperable due to the power cord of the unit not being long enough to reach the power outlet. 2. Room A9 has a mattress that sags and there is a hole in the middle on the bed against the wall. 3. Room C8 has broken blinds leaving a five inch by 24 inch gap of uncovered window. 4. Room C11 has broken blinds leaving a four inch by six inch gap of uncovered window. 5. Room C20?s window blinds had broken slats and the pillows on both beds in C20 were worn flat and bunched up
Plan of Correction:	In room B9, an extender has been placed on the power cord of the heating and air system to allow it to operate as intended. The mattress in B9 on the bed against the wall has been replaced. The blinds in room C8 have been replaced. The blinds in room C11 have been replaced. The blinds in room C20 have been replaced. The pillows on both beds in C20 have been replaced. In the future, housekeeping staff will monitor the rooms to ensure that all furniture, fixtures, and equipment are kept clean and in good repair. [sic]
Standard #:	22VAC40-73-890-D
Description:	Based on observations made during the tour of the building, the facility failed to ensure fluorescent lights be replaced if they flicker or make noise. EVIDENCE: 1. Resident Room B6 has a light over the bed against the wall, this light flickers
Plan of Correction:	Resident room B6 light over the bed against the wall has been replaced. In the future, nursing staff will alert maintenance of any lighting issues that need to be addressed. [sic]
Standard #:	22VAC40-73-920-C
Description:	Based on observations made during the tour of the building, the facility failed to ensure there was ventilation to the outside to eliminate foul odors in all bathrooms. EVIDENCE: 1. Room #B8 did not have a working fan in the bathroom. 2. Room #B9?s vent fan in the bathroom was inoperable. 3. Vent system on A and B hall in bathrooms were inoperable.
Plan of Correction:	Room #B8 and #B9 vent fan in the bathrooms were replaced with working vent fans. The vent system on A and B is being replaced with new vent fans in every room. In the future, housekeeping will monitor bathrooms for ventilation issues that may need to be addressed and inform maintenance. [sic]
Standard #:	22VAC40-73-940-A
Description:	Based on documents presented during the licensing inspection, the facility failed to produce documentation to show they were in compliance with the Virginia Statewide Fire Prevention Code as determined by an annual inspection by the appropriate fire official. EVIDENCE: 1. On the date of the inspection (05/10/2022) the facility was not able to show the documentation of the annual fire inspection.
Plan of Correction:	The Fire Marshall will be at the Facility on 06/21/2022 to conduct the annual fire inspection. In the future, the Business & Operations Manager will ensure that the annual fire inspection is performed in the allotted time frame. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records, the facility failed to obtain a criminal history report on or prior to the 30th day of employment: EVIDENCE: 1. Staff #7 began employment on 08/02/2021. The criminal history record report was obtained on 12/06/2021. 2. Staff # 8 began employment on 09/09/2021. The criminal history record report was obtained on 10/15/2021
Plan of Correction:	In the future, the Administrator will ensure that all Criminal Background Checks are performed in a timely manner and are obtained within the 30 th day of employment. [sic]
Standard #:	22VAC40-90-40-C
Description:	Based on review of staff records, the facility failed to ensure a person with a barrier crime listed on his or her criminal history record report was ineligible for employment. EVIDENCE: 1. Staff#6 began employment on 05/26/2021. The criminal history record report was obtained on 06/16/2021. Staff #6 is ineligible for employment due to the conviction of a barrier crime.
Plan of Correction:	Staff #6 was terminated from employment. In the future, the Administrator will ensure that no employee is employed at the facility that has a barrier crime conviction. [sic]
Standard #:	22VAC40-90-40-F
Description:	Based on review of staff records, the facility failed to have a criminal record report issued by the State Police dated no more than 90 days prior to employment. EVIDENCE: 1. Staff #12 began employment on 02/23/2022. The criminal history record report was obtained on 02/26/2021
Plan of Correction:	A new Criminal Background Check has been ordered for Staff #12. In the future, the Administrator will ensure that all Criminal Background Checks are performed are performed in a timely manner and are dated not more than 90 days prior to employment. [sic]