VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Guardian Light, LLC
2101 Mountain Run Drive
Glen allen, VA 23060
(804) 261-5824

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Jan. 26, 2023 and Feb. 3, 2023

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 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

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: 1-26-23 from 9:50 a.m.- 1:00 p.m. and 2-3-23 from 7:45 a.m.- 8:30 a.m. 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: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, emergency food and water, medication pass, physician?s orders and medication administration records (MARs). An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The record for Staff # 1 (date of hire: 4-9-16) contained a TB screening last dated 2-12-2018.
Plan of Correction:	Administrator will remind staff when annual documents are needed.
Standard #:	22VAC40-73-400
Description:	Based on a review of resident records the facility failed to ensure that it provided to each resident or the resident?s legal representative, if one has been appointed, a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance due or any credits for overpayment. Evidence: The record for Resident #1, #2, #3, and # 4 did not contain a monthly statement of charges and payments.
Plan of Correction:	Staff will ensure that residents/legal representatives receive monthly receipts.
Standard #:	22VAC40-73-650-E
Description:	Based on a review of resident records the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Evidence: The record for Resident # 5 did not contain signed physician?s orders. The administrator stated that the facility had not received the signed orders yet.
Plan of Correction:	Staff will request all physician's orders not received.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of facility documentation the facility failed to ensure that it conducted monthly fire drills. Evidence: The fire and evacuation drill last documented by the facility was dated 9-20-22.
Plan of Correction:	Staff will be retrained on completing monthly fire drills.
Standard #:	22VAC40-73-980-A
Description:	Based on a review of the facility?s first aid kit the facility failed to ensure that the first aid kit contained all required items. Evidence: The facility?s first aid kit did not contain extra batteries.
Plan of Correction:	Staff will check first aid kit monthly.
Standard #:	22VAC40-73-980-C
Description:	Based on a review of the facility?s first aid kit the facility failed to ensure that first aid kit shall be checked at least monthly to ensure that all items are present. Evidence: The facility did not have documentation of the first aid kit being checked monthly and the administrator stated that she did not know when it was last checked.
Plan of Correction:	Facility will put in place procedures to check first aid kit monthly.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The facility could not provide documentation of a practice exercise for a resident emergency within the past six months.
Plan of Correction:	Staff will be retrained and reminded to complete exercises for resident emergencies.