VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Haven Assisted Living @ Sandy Valley
4350 Sandy Valley Road
Mechanicsville, VA 23111
(804) 779-3154

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Aug. 19, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 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: 08/19/2024 Arrival time: 10:50am Departure time: 12:50pm 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: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. 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. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident record, it was determined that the facility did not ensure that all residents shall have a physical examination within the 30 days preceding admission by an independent physician. Evidence: 1. The Physical Examination in the record for resident #2 was dated 2/29/24. 2. The date of admission for resident # 2 was 5/2/24. 3. Staff # 3 reviewed the record for resident #2 and was unable to provide documentation during the onsite inspection that the physical examination for resident #2 was completed within 30 days preceding admission.
Plan of Correction:	Administrator will ensure that Physical will be updated. Currently waiting on the Doctor for appointment.
Standard #:	22VAC40-73-450-A
Description:	Based on a review of resident record, it was determined that the facility did not ensure a valid indication of Do Not Resuscitate Order (DNR) for withholding cardiopulmonary resuscitation or proceeding with Cardiopulmonary Resuscitation (CPR) for a resident in the event of cardiac or respiratory arrest in the resident?s Individualized Service Plan (ISP). Evidence: 1. The ISP did not indicate a Do Not Resuscitate (DNR) order nor was there an indication of Cardiopulmonary Resuscitation (CPR) in the record for resident #1. 2. Staff #3 was unable to provide documentation that indicated Do Not Resuscitate Order (DNR) or Cardiopulmonary Resuscitation (CPR) within the ISP in the record of resident #1
Plan of Correction:	The Administrator will Ensure that the proper documentation be placed in resident file
Standard #:	22VAC40-73-550-G
Description:	Based on the review of resident records, it was determined that the facility did not ensure that the Rights and Responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated. Evidence: 1. The record for resident #2 contained a Resident Rights and Responsibilities that was dated 8/4/23. 2. Staff # 3 reviewed the record for resident #2 and was unable to provide documentation during the onsite inspection that the annual review of Resident Rights and Responsibilities for resident #2 was completed.
Plan of Correction:	Administrator carefully will review residents file to ensure the there is nothing missed on the forms.