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: April 25, 2023

Complaint Related: Yes

Areas Reviewed:

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

Technical Assistance:

1. The review of Rights and Responsibilities of Residents must be signed and dated by each resident/legal representative and staff to ensure written acknowledgment of the review. 2. The direct care training certificate must be signed by the nurse that taught the class, not the administrator of the facility.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/25/2023 from approximately 10:55 am to 7:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/12/2023 regarding allegations in the areas of: Administration, Personnel, Staffing, Admission, Retention, Discharge of Residents, Resident Accommodations, Building and Grounds and Emergency Preparedness. Number of residents present at the facility at the beginning of the inspection: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 + selected sections of 5 additional records Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Staff and resident interactions, resident rooms, etc. Additional Comments/Discussion: Interviews were conducted with residents, a family member and staff. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were in the areas of: Personnel; Admission, Retention and Discharge of Residents. A violation notice was issued; any violation(s) not related to the complaint 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Complaint related:	No
Description:	Based upon documentation and an interview, the facility failed to ensure two of the four staff completed first aid (FA) training within 60 days of hire. Evidence: 1. Staff 3 and 4 (hired October 2022) completed FA training on 3/14/2023. 2. On 4/25/2023, the LI interviewed the administrator who stated the staff did not complete FA training within 60 days of hire and the 3/14/2023 training was the only FA training completion on file.
Plan of Correction:	Administrator reviewed all staff records on 5/10/23 for compliance. Administrator will review all new hire certifications upon hire and ensure FA is completed within 60 days of hire.
Standard #:	22VAC40-73-260-C
Complaint related:	No
Description:	Based upon documentation and an interview, the facility failed to ensure the posted list of staff with current FA and cardiopulmonary resuscitation training (CPR) was kept up to date. Evidence: 1.The posted list included staff 10, 11, 12 and 13. 2. On 4/25/2023, the LI interviewed the administrator who reviewed the list and stated staff 10, 11, 12 and 13 were no longer employed at the facility.
Plan of Correction:	Administrator updated and posted current list on 5/12/23. Administrator will ensure posted list of staff with FA and CPR is up to date, displaying FA and CPR certified staff in accordance with current employe roster.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure fall risk ratings were completed after each fall for one of three resident records reviewed. Evidence: 1. Resident 2 had incident reports for falls 4/17/2022, 5/14/2022, 8/1/2022 and 1/23/2023; however, there were no fall risk ratings on file for these incidents. 2. On 4/25/2023, the LI interviewed the administrator who checked the files and stated there were no fall risk ratings completed for these incidents.
Plan of Correction:	Administrator completed and updated residents fall risk rating on 5/08/23. Administrator and Resident Care Director will review all falls to ensure fall risk ratings are completed at time of incident and policy is followed. Administrator or Resident Care Director will complete a falls and fall risk rating staff re-training by 5/15/23, to ensure continued compliance.
Standard #:	22VAC40-73-350-A
Complaint related:	Yes
Description:	Based upon interviews, the facility failed to ensure registration was completed and remained current with the Department of State Police in order to receive notifications of sex offenders residing in the facility?s zip code area. Evidence: 1. On 4/25/2023, the LI asked the administrator to provide verification of registration with the state police for receiving sex offender registry notifications and she stated she had not received any notifications since employed at the facility. She also stated she did not have any kind of verification of the facility being registered. 2. On 4/26/2023, the licensee contacted LI by email and stated they would contact LI if they found anything regarding the facility being registered. He stated they were receiving the notifications when he was the administrator in October 2021. No verification was provided regarding the facility being registered.
Plan of Correction:	Administrator registered the community with Department of State Police on 5/11/23. All Sex Offender notifications will be available to residents and their representatives at all times.
Standard #:	22VAC40-73-350-C
Complaint related:	Yes
Description:	Based upon record reviews and an interview, the facility failed to ensure sex offender registry information was reviewed annually for one of three resident records reviewed. Evidence: 1. Resident 3 (admitted 9/4/2017) had no documentation on file of an annual review of the sex offender registry information. 2. On 4/25/2023, the LI interviewed the administrator who stated they did not have documentation of annual reviews of the sex offender registry information for residents
Plan of Correction:	Administrator will review Sex Offender Registry standard with all residents and document by completion of an acknowledgement form, signed and dated by resident or resident representative by 5/15/23 and annually.
Standard #:	22VAC40-73-550-G
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure written acknowledgement of an annual review of the rights and responsibilities of residents was documented in five of eight staff records reviewed. Evidence: 1. The training records for staff 5, 6, 7, 8 and 9 listed resident rights and the date training was completed; however, the training record was not signed by the staff and no training sign-in sheets were in the records. 2. On 4/25/2023, the LI interviewed the administrator who stated they did not have the staff sign or have the staffs? written acknowledgement that they completed an annual review of the residents rights.
Plan of Correction:	Administrator completed an additional review of Residents Rights with each staff member. Training was documented by completing an acknowledgement form, signed and dated 4/24/23. Administrator will ensure the acknowledgement form is utilized upon hire and annually.
Standard #:	22VAC40-73-560-H
Complaint related:	No
Description:	Based upon interviews, the facility failed to ensure one of one discharge record remained on site for at least the first year after discharge. Evidence: On 4/25/2023, the LI requested to review the record for resident 1 (discharged 12/14/2022). The wellness coordinator and administrator both stated the record was off site in storage and could not be obtained on the day of the inspection.
Plan of Correction:	Administrator or Resident Care Director will ensure that all residents records are kept onsite in community storage area and available for one year, as per standard. Administrator will monitor monthly.
Standard #:	22VAC40-73-610-B
Complaint related:	Yes
Description:	Based upon observations, documentation and an interview, the facility failed to ensure menus were dated. Evidence: 1. On 4/25/2023, the LI observed the posted menu by the dining room. The holder for the menu also included three additional menus. None of the menus were dated. The menus only included the week number and day of the week ? no month, day or year. 2. On 4/25/2023, the LI interviewed the administrator who checked the menus with the LI and stated the menus were not dated. 3. On 4/25/2023, the LI interviewed the dietary manager who stated they had not been putting dates on the menus.
Plan of Correction:	Administrator retrained dietary manager on 5/10/23, to ensure menu is posted with month with daily dates and resident copies of menus are complete with daily dates. Administrator, Resident Care Director or Dietary Manager will review monthly as menu is posted, for continued compliance.
Standard #:	22VAC40-73-620-A
Complaint related:	Yes
Description:	Based upon interviews, the facility failed to ensure dietary reviews were conducted at least once every six months. Evidence: 1. On 4/25/2023, the licensing inspector (LI) requested the administrator provide the dietary reviews from the previous year. A dietary review dated 3/22/2023 was the only review provided. 2. On 4/25/2023, the LI interviewed the administrator who stated the facility did not have a dietitian when she started as administrator in October 2022. 3. On 4/25/2023, the LI interviewed the dietary manager who stated they did not have any dietary reviews and that ?a dietary review has not been completed since before COVID.?
Plan of Correction:	Registered Dietitian is contracted and completed dietary review 3/9/23. The Administrator will ensure the contracted Dietitian completes resident diet review semi-annually for each resident and will ensure review results are available to the inspector upon request. Timberview was unable to secure a Dietitian post Covid, to complete dietary services. The licensing inspector was notified by Administrator and CEO of parent company. Dietitian was secured in March of 2023 and completed review on March 9, 2023.