VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Timberview Crossing
351 New Market Road
Timberville, VA 22853
(540) 896-9858

Current Inspector: Jill James (540) 418-2631

Inspection Date: Aug. 11, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Protection of adults and reporting.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 08/11/20 and concluded on 09/09/20. A self-reported incident was received by the department regarding allegations in incident reporting, reports of abuse, neglect, or exploitation, administrator responsibilities and resident rights. Kelly Good (administrator) was contacted to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self report of non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based upon documentation and communication, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1) The facility reported to the licensing office on 08/11/20 that Adult Protective Services (APS) had been notified of inappropriate touching between a competent male resident and a cognitively dementia female resident that occurred on 08/09/20. a. Documentation indicates there were two incidents that occurred with these residents on 08/09/20 at 11:00am and 4:00pm and again on 08/10/20 at 2:30pm. b. Documentation indicates incidents of inappropriate touching occurred between the same residents on 03/30/19, 06/02/19 and 01/20/20. c. The incidents from 03/30/19, 06/02/19, 01/20/20 and 08/10/20 were not reported to the licensing office or APS until investigation of the 08/09/20 incident.
Plan of Correction:	Administrator or Designee will review with all staff the policy/procedure formandated reporting and the importance of verbal reporting in a timely manner. Administrator or Designee will report to the Regional Licensing Office within 24 hours of any incident that effects or threatens the life, health, safety, or welfare of a resident
Standard #:	22VAC40-73-70-B
Description:	Based upon documentation and communication, the facility failed to submit a written report to the regional licensing office within 7 days of the date of the incident. EVIDENCE: 1) The facility reported to the licensing office on 08/11/20 that Adult Protective Services (APS) had been notified of inappropriate touching between a competent male resident A and a cognitively dementia female resident B that occurred on 08/09/20. a. Documentation indicates there were two incidents that occurred with these residents on 08/09/20 at 11:00am and 4:00pm and again on 08/10/20 at 2:30pm. b. Documentation indicates incidents of inappropriate touching occurred between the same residents on 03/30/19, 06/02/19 and 01/20/20. c. The incidents from 03/30/19, 06/02/19, 01/20/20 and 08/10/20 were not reported to the licensing office or APS until investigation of the 08/09/20 incident.
Plan of Correction:	Administrator or Designee will submit to the Regional Licensing Office a full written report within 7 days of the incident.
Standard #:	22VAC40-73-130-A
Description:	Based upon review of documentation, the facility staff failed to report suspected abuse, neglect, or exploitation as per 63.2-1606 of the Code of Virginia. EVIDENCE: 1) The facility reported to the licensing office on 08/11/20 that Adult Protective Services (APS) had been notified of inappropriate touching between a competent male resident A and a cognitively dementia female resident B that occurred on 08/09/20. a. Documentation indicates there were two incidents that occurred with these residents on 08/09/20 at 11:00am and 4:00pm and again on 08/10/20 at 2:30pm. b. Documentation indicates incidents of inappropriate touching occurred between the same residents on 03/30/19, 06/02/19 and 01/20/20. c. The incidents from 03/30/19, 06/02/19, 01/20/20 and 08/10/20 were not reported to the licensing office or APS until investigation of the 08/09/20 incident.
Plan of Correction:	Administrator or Designee will notify the Regional Licensing Office and Adult Protective Services within 24 hours of any concerns for abuse, neglect, or exploitation.
Standard #:	22VAC40-73-150-C
Description:	Based upon documentation and communication, the administrator failed to ensure that care is provided to residents in a manner that protects their health, safety and well-being. EVIDENCE: 1) The facility reported to the licensing office on 08/11/20 that Adult Protective Services (APS) had been notified of inappropriate touching between a competent male resident A and a cognitively dementia female resident B that occurred on 08/09/20. a. Documentation indicates there were two incidents that occurred with these residents on 08/09/20 at 11:00am and 4:00pm and again on 08/10/20 at 2:30pm. b. Documentation indicates incidents of inappropriate touching occurred between the same residents on 03/30/19, 06/02/19 and 01/20/20. c. The incidents from 03/30/19, 06/02/19, 01/20/20 and 08/10/20 were not reported to the licensing office or APS until investigation of the 08/09/20 incident. d. The competent male resident A was sent to the ER on 08/11/20 and an emergency protective order was filed. Resident A was officially discharged from the facility on 08/12/20.
Plan of Correction:	Administrator reviewed the regulations and will notify the Regional Licensing and Adult Protective Services with any concerns for abuse, neglect, and/or exploitation.
Standard #:	22VAC40-73-550-C
Description:	Based upon communication and documentation, the facility failed to ensure a resident is free from mental, emotional, physical, sexual, and economic abuse or exploitation; is free from forced isolation, threats or other degrading or demeaning acts against him; and his known needs are not neglected or ignored by personnel of the facility. EVIDENCE: 1) The facility reported to the licensing office on 08/11/20 that Adult Protective Services (APS) had been notified of inappropriate touching between a competent male resident A and a cognitively dementia female resident B that occurred on 08/09/20. a. Documentation indicates there were two incidents that occurred with these residents on 08/09/20 at 11:00am and 4:00pm and again on 08/10/20 at 2:30pm. b. Documentation indicates incidents of inappropriate touching occurred between the same residents on 03/30/19, 06/02/19 and 01/20/20. c. The incidents from 03/30/19, 06/02/19, 01/20/20 and 08/10/20 were not reported to the licensing office or APS until investigation of the 08/09/20 incident. d. The competent male resident was sent to the ER on 08/11/20 and an emergency protective order was filed. Resident A was officially discharged from the facility on 08/12/20.
Plan of Correction:	Administrator or Designee will review with all staff, resident's rights and to report any concerns immediately to the Administrator or Designee.