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 13, 2024 and March 14, 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 22VAC40-90 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: 03/13/2024 10:28am to 3:10pm and 03/14/2024 10:12am to 1:51pm 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-40-B-8
Description:	Based on observations made during the tour of the building and interview with staff, the facility failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public. EVIDENCE: 1. The license posted in the facility at the time of inspection expired 04/30/2023. 2. Staff #6 confirmed the current license was not posted elsewhere in the facility.
Plan of Correction:	The current license was posted in a place conspicuous to the residents and the public. The Administrator will ensure that the current license is always posted in a place conspicuous to the residents and the public. [SIC]
Standard #:	22VAC40-73-610-E
Description:	Based on observations made during the tour of the building and interview with staff, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition shall be kept current and readily available to personnel responsible for food preparation. EVIDENCE: 1. Staff #8 was unable to locate a diet manual in the kitchen or elsewhere in the building. 2. Staff #7 was also not aware of a diet manual kept in the facility.
Plan of Correction:	The diet manual containing acceptable practices and standards for nutrition was printed on 03/13/2024 while the Licensing Inspector (LI) was at the facility. Administrators will ensure that the diet manual will be kept current and readily available to personnel responsible for food preparation. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure each bedroom shall contain all required items. EVIDENCE: 1. There are two residents assigned to room A17 and the LI observed only one operable bed lamp or bedside light in the room.
Plan of Correction:	1. A second operable bed lamp was installed in A17. The Administrator will ensure that all bedrooms contain all required items. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair. EVIDENCE: 1. In the bathroom for resident room A15, the paint just above the baseboards beside and behind the toilet was peeling. In the same bathroom, the metal strips between the ceiling tiles appeared to be covered in rust. 2. In resident room B21, the lower portion of the wall to the left of the bathroom door had peeling/chipped paint, dark marks and indentations, and a portion of the baseboard was coming apart from the wall. 3. In the bathroom for resident room B3, the flooring tiles on both sides of the toilet were stained with what appeared to be water damage and there was a dark stain on the floor around the base of the toilet where it meets the floor. 4. In the bathroom for resident room B5, there was a dark stain on the flooring in front of and to the right where the base of the toilet meets the floor. In the same bathroom, the baseboard had separated from the wall where it meets the bathtub on the left side.
Plan of Correction:	In A 15 the bathroom wall was painted. The metal strips between the ceiling tiles were painted. 2. The wall in B21 was painted. The baseboard was replaced. 3. The floor tiles in B3 were replaced. 4. The floor tiles in B5 were replaced. The baseboard was replaced. The Administrator will ensure that the interior and the exterior of all buildings shall be maintained and in good repair. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. In the bathroom for resident room B18, the caulking around the base of toilet was stained and separating from the toilet in some areas. 2. In the bathroom for resident room B15, the caulking around the base of toilet was cracked and separating from the floor in some areas. In the same bathroom, the caulking at the base of the bathtub was lightly stained. 3. In the bathroom for resident room B3, the caulking at the base of the bathtub was lightly stained and had separated from the bathtub.
Plan of Correction:	1. The caulking around the toilet in B18 was replaced. 2. The caulking around the toilet and the bathtub in B15 was replaced. 3. The caulking around the bathtub in B3 was replaced. The Administrator will ensure that all furnishings, fixtures, and equipment including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. [SIC]