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: Aug. 1, 2023 , Aug. 8, 2023 and Oct. 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 08/01/2023 12:39pm to 1:43pm, 08/08/2023 12:45pm to 2:35pm, 10/23/2023 11:30am to 11:46am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/01/2023 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-460-D
Description:	Based on facility self-report and a review of resident records, the facility failed to provide supervision of resident schedules, care and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) for resident #1, completed 10/27/2022, identified disoriented ? some spheres, some of the time (time, place), short-term and long-term memory loss and judgement problems and wandering/passive ? weekly or more as areas in which resident #1 required assistance. 2. Per facility documentation via Nurses Progress Notes, there were several occasions in which resident #1 attempted to wander from the facility including the following: a. On 03/30/2023, staff #10 noted staff were alerted by staff #4 that resident #1 had exited the facility. Staff #4 and staff #5 went outside to get resident #1 due to the facility being located close to the road. b. On 04/05/2023, staff #11 noted resident #1 exited the facility and went across the parking lot to a medical office looking for a church that cashed his check. Resident #1 was brought back to facility. He stated ?I was coming back I was just seeing if that was the place I needed to go.? Staff #11 noted resident #1 was advised to not leave the facility, as it could be dangerous. c. On 04/08/2023, staff #7 documented resident #1 was opening the fire doors all night and going outside. d. On 04/09-04/10/2023, staff #7 noted resident #1 was awake all night, going outside via the fire doors and pacing the halls. e. On 04/12/2023 12:45am to 1:10am, staff #12 noted resident #1 was attempting to go outside to the courtyard to urinate. Resident #1 was stopped by staff and informed that he could not urinate in the courtyard. f. On 04/21-22/2023, staff #7 noted resident #1 was awake all night and tried several times to go outside; resident #1 was stopped by staff and informed of the time and bad weather conditions. 3. LI was notified by staff #1 via phone call on 08/01/2023 at 8:30am that resident #1 wandered from the facility around 11:00pm on 07/31/2023 and was hit by a car at a nearby intersection; resident #1 did not survive his injuries. 4. Per video footage observed by LI, resident #1 exited the facility at the end of A hallway at 11:11pm on 07/31/2023. He is seen again at 11:24pm via another video camera?s footage walking around a corner near the front of the building. Per documentation by staff #7, at 11:59pm a deputy came to the facility and notified staff that resident #1 had been hit by a car and was deceased. Staff #7 was asked by the deputy to identify the resident; staff #7 was able to verify the deceased was resident #1.
Plan of Correction:	Not available online. Contact Inspector for more information.