VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Jan's Residential Home I
307 N. High Street
P. O. Box 666
Blackstone, VA 23824
(434) 298-0993

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: May 9, 2022

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 ? 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 ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Technical Assistance:

Emergency food expiration dates (some expired)

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: 5/09/2022, 9:30 a.m. ? noon The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review, 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. Resident #1?s ?Resident?s Notes? dated 12-18-2021 ? 12-27-2021 documented, ?Resident [#1] admitted to [hospital] due to testing positive for Covid-19.? 2. Licensing staff was not made aware of Resident #1?s incident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure the personal and social data was maintained on staff and included in the staff record such as: the date employed, verification that the staff person has received a copy of his current job description, an original criminal record report and a sworn disclosure statement, documentation of qualifications for employment related to the staff person's position, including any specified relevant information, verification of current professional license, certification, registration, medication aide provisional authorization, or completion of a required approved training course, name and telephone number of person to contact in an emergency, and documentation of orientation, training, and education required by this chapter, including any specified relevant information, with annual training requirements determined by starting date of employment. Evidence: 1. Staff #2?s record did not have the following: the date employed, verification that the staff person has received a copy of his current job description, an original criminal record report and a sworn disclosure statement, documentation of qualifications for employment related to the staff person's position, including any specified relevant information, verification of current professional license, certification, registration, medication aide provisional authorization, or completion of a required approved training course, name and telephone number of person to contact in an emergency, and documentation of orientation, training, and education required by this chapter, including any specified relevant information, with annual training requirements determined by starting date of employment. 2. Staff #3?s record did not contain the same above information, aside from the emergency contact information which Staff #3?s record did contain.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-D
Description:	Based upon record review, the facility failed to ensure copies of the written assurance were signed by the resident or his legal representative and kept in the resident's record. Evidence: 1. Resident #1 admitted 4-06-2021. The written assurance form in the record was blank with no signatures or dates.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure all residents? uniform assessment instruments (UAIs) were completed at least annually. Evidence: 1. Resident #6 admitted 8-01-2019. The resident?s only UAI in the record was dated 7-20-2019, and no more current UAI was in the record. 2. Staff #1 acknowledged phone interview on 7-20-2022 and stated, "It's hard to get them [agency] to send them."
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care (ISP) was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. Resident #2 admitted 12-07-2021. The only ISP in the record was dated 1-07-2022, and no prior ISP was in the record. 2. Staff #1 acknowledged during phone interview on 7-20-2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the uniform assessment instrument (UAI), admission physical examination, and other sources. Evidence: 1. Resident #2 admitted 12-07-2021. The resident?s UAI dated 12-06-2021 documented identified needs of transportation, shopping and housekeeping; however, the only ISP in the record dated 1-07-2022 did not document any of those needs. 2. Resident #3 admitted 2-08-2021. The resident?s UAI dated 11-10-2020 documented identified needs of home maintenance, housekeeping, and shopping; however, the only ISP in the record dated 3-25-2021 did not document any of those needs. Additionally, Resident #3?s physician?s orders dated 6-22-2021 documented allergies to amoxicillin and penicillins; however, the ISP did not document the allergies or allergy reactions.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. Evidence: 1. The following ISPs were not reviewed and updated at least once every 12 months: a. Resident #3 admitted 2-08-2021 and only ISP in the record was dated 3-25-2021. b. Resident #1 admitted 4-6-2021 and only ISP in the record was dated 4-06-2021. The resident?s UAI dated 3-03-2022 documented identified needs of transferring, walking, stairclimbing, mobility as needing mechanical assistance; however, the only ISP in the record dated 4-06-2021 did not did not document any of those needs. Staff #1 stated Resident #1 ?holds railing while using stairs and has a rollator walker?. c. Resident #4 admitted 3-16-2021 and only ISP in the record was dated 4-01-2021. d. Resident #5 admitted 2-06-2014 and only ISP in the record was dated 10-09-2020. 2. Staff #1 acknowledged during phone interview on 7-20-2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-A
Description:	Based on record review, the facility failed to ensure that health care oversight was provided by a licensed health care professional at least annually. Evidence: 1. Documentation of healthcare oversight was requested onsite on 5-09-2022 but Staff #1 could not locate them. Staff #1 was additionally asked to email the documents on 5-12-2022 and 6-07-2022; however they were not provided. 2. Staff #1 acknowledged during phone interview on 7-20-2022 that it had not been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-520-I
Description:	Based on review and interview with staff, the facility failed to ensure there was a written schedule of activities developed at least monthly. Evidence: 1. The Activities Calendar provided by Staff #1 on the date of inspection on 5-09-2022 was dated December 2021. 2. Staff #1 stated the activities remain the same month to month.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: 1. Resident #1 admitted 4-06-2021. The ?rights and responsibilities of residents in assisted living facilities? located in the resident?s file was not signed or acknowledged as there was no signature from the resident, legal representative or responsible individual. 2. Resident #2 admitted 12-07-2021. The ?rights and responsibilities of residents in assisted living facilities? located in the resident?s file was not signed or acknowledged as there was no signature from the resident, legal representative or responsible individual. 3. Resident #3 admitted 2-08-2021. The ?rights and responsibilities of residents in assisted living facilities? located in the resident?s file was last signed 1-29-2020. 4. Resident #4 admitted 3-16-2021. The ?rights and responsibilities of residents in assisted living facilities? located in the resident?s file was last signed 4-01-2021. 5. Resident #5 admitted 2-06-2014. The ?rights and responsibilities of residents in assisted living facilities? located in the resident?s file was last signed 3-01-2020.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-I
Description:	Based on record review, the facility failed to ensure a current picture of each resident or narrative physical description was readily available for identification purposes. Evidence: 1. Resident #1 admitted 4-06-2021. Resident #2 admitted 12-07-2021. Neither Resident #1 nor Resident #2?s records contained a photo nor a narrative physical description of the resident. 2. Staff #1 acknowledged she did not have a photo nor narrative physical description for these residents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on record review, the facility failed to ensure a record was kept of menus for meals and snacks of food served over the licensure period. Evidence: 1. The last three months? menus were requested by licensing staff onsite during the inspection as well as on 5-12-2022 and 6-07-2022; however, the menus were not provided.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-750-B
Description:	Based on observation and interview with staff, the facility failed to ensure bedrooms contained an operable bed lamp or bedside light accessible to each resident. Evidence: 1. During tour with Staff #1 on 5-09-2022, room 2A and room 2B contained no lamps in the rooms for two residents each. Room 3A had no lamp for two residents, and room 3B had one lamp for two residents. 2. Staff #1 was present throughout the tour and acknowledged the lamps were not in the four rooms as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure all furnishings, including furniture was kept in good repair and condition. Evidence: 1. The dresser located in room 2A on the far left wall was missing a dresser drawer on the bottom left side of the dresser. 2. Staff #1 was present with the inspector during the tour and observed the missing dresser drawer located in the room.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-940-A
Description:	Based on record review, the facility failed to ensure an assisted living facility complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: 1. There was no annual inspection in accordance with the Virginia Statewide Fire Prevention Code by the local fire agency. 2. The date of the last fire inspection is unknown due to no response from the provider.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure the fire and emergency evacuation drawing showed the primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate. Evidence: 1. The fire and emergency evacuation drawing posted in the facility did not contain specification of the primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes and fire extinguishers.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-B
Description:	Based on record review, the facility failed to ensure the procedures in the plan for resident emergencies required was reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person. Evidence: 1. Documentation of review of the plan for resident emergencies was requested onsite on 5-09-2022 but Staff #1 could not locate any of these records. Staff #1 was additionally asked to email the documents on 5-12-2022 and 6-07-2022; however they were not provided.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-A-1
Description:	Based on record review, the facility failed to operate within the terms of its license, which include the operating name of the facility. Evidence: 1. A facsimile sheet located in Resident #3?s record dated 7-16-2021 was addressed to [Agency Name] documented ?New Day Residential Home? and identified it as ?Change in facility name and banking information?. No modification request was received by the licensing office to change the facility?s name. 2. The State Corporation Commission website documented the ?Formation Date? of the LLC as 7-08-2021. The ?Registered Agent? is listed as Staff #1. 3.Staff #1 stated that she planned to change the name but didn?t do it.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the facility failed to ensure the findings of the most recent inspection of the facility were posted on the premises. Evidence: 1. During inspection on 5-09-2022, the most recent inspection notice posted was from 12-14-2018. There have been eleven inspections since that time.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #2 and Staff #3?s records did not contain criminal history record reports. Licensing staff could not determine the staff?s dates of hires based on the records.
Plan of Correction:	Not available online. Contact Inspector for more information.