VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Dec. 21, 2022

Complaint Related: No

Areas Reviewed:

MARK AREAS 22VAC40-73 GENERAL PROVISIONS XX 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS XX 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS XX 22VAC40-73 BUILDINGS AND GROUND XX 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 XX 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:

Old resident agreement/paperwork updated

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: 12-21-2022, 7:41 a.m. ? 10:30 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: 10 Number of resident records reviewed: 6 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Buildings and grounds, emergency preparedness, first aid kit, meal, records, interviews 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. 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 #:	22VAC40-73-40-B-9
Description:	Based on record review and interview with staff, the licensee failed to ensure that the facility keeps and maintains at the facility records as required by this chapter for licensed assisted living facilities. Evidence: Staff #2 and Staff #3?s records were requested as part of the inspection; however, Staff #1 stated that the records were offsite and not available during inspection. Requested again via email 12-22-2022 and as of 12-31-2022 the records were still not available or onsite to be sent to inspector for review.
Plan of Correction:	ALL DOCUMENTS TO BE VERIFIED AND KEPT UP TO DATE ON SITE AS REQUIRED; THIS WILL BE DONE USING VDSS MODEL FORM 032-05-0528-02 (02/18) TO ENSURE A COMPLETED FILE; SEE ATTACHED FORM AT BOTTOM OF THIS EMAIL
Standard #:	22VAC40-73-590-B
Description:	Based on record review and interview with staff, the facility failed to ensure snacks were made available at all times for all residents. Evidence: 1. An ?Incident/Accident Report Form? dated 11-06-2022 at 6:44 p.m. documented regarding Resident #2, ?Resident [#2] asked for a piece of bread and staff let him know [Staff #2] could not give [Resident #2] a slice of bread then [Resident #2] keeps speaking telling [Staff #2] about [Staff #2?s] religion?? 2. During interview with Staff #1, Staff #1 acknowledged Staff #2 had denied Resident #2 bread and that Staff #1 did speak with staff regarding the incident.
Plan of Correction:	SNACK TIME IS AVAILABLE AT ALL TIMES AT JANS; THIS HAS REITERATED WITH STAFF AND SHOULD NOT HAPPEN AGAIN;
Standard #:	22VAC40-73-650-B
Description:	Based on record review, the facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. The following two residents? listed drugs did not identify the diagnosis, condition, or specific indications for administering each drug: a. Resident #4?s physician?s orders dated 12-21-2022 for Maxzide 37.5-25 mg, Zyrtec 10 mg, and Pepcid 40 mg; and b. Resident #5?s physician?s orders dated 12-21-2022 for Invega Sustenna 234mg/1.5 mL, Pepcid 40 mg, Depakote 500 mg, Cogentin 1 mg, Desyrel 50 mg, Melatonin 3 mg, Haldol 10 mg, and Prilosec 20 mg.
Plan of Correction:	THIS VIOLATION HAS BEEN CORRECTED WITHIN JANS RESIDENTIAL AND WITH PARTNERING PHARMACIES; WILL BE COMMUNICATED WITH ALL PHYSICIANS MOVING FORWARD USING VDSS FORM ? 032-05-0530-02 (2/18); SEE ATTACHED FORM AT BOTTOM OF THIS EMAIL
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug. Evidence: Resident?s #5?s October 2022 MAR did not include the diagnosis, condition, or specific indications for each medication: Invega Susten 234mg/1.5mL; Pepcid 40 mg, Depakote DR 500 mg, Cogentin 1 mg, Trazodone 50 mg, and Haldol 10 mg.
Plan of Correction:	THIS VIOLATION HAS BEEN CORRECTED WITHIN JANS RESIDENTIAL AND WITH PARTNERING PHARMACIES; WILL BE COMMUNICATED WITH ALL PHYSICIANS MOVING FORWARD USING VDSS FORM ? 032-05-0530-02 (2/18); SEE ATTACHED FORM AT BOTTOM OF THIS EMAIL
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview with staff, the facility failed to ensure the interior of the building was kept clean. Evidence: 1. The second floor shared bathroom?s ceiling had dozens of black dots ranging in sizes from small to medium size around the perimeters of the ceiling and above the shower, toilet, and sinks. 2. Staff #1 confirmed it appeared 3-4 days prior and that it had not been cleaned. Photographic evidence was obtained.
Plan of Correction:	IMMEDIATE REMEDY WAS TO CLEAN CEILING OF IDENTIFIED SPOTS; BTHROOMS TO BE INCLUDED IN SCHEDULED RENOVATIONS
Standard #:	22VAC40-73-925-B
Description:	Based on observation and interview with staff, the facility failed to ensure common face/hand washing sinks had paper towels and liquid hand soap for hand washing. Evidence: 1. The downstairs common bathroom hand washing sink did not contain paper towels and liquid hand soap. 2. Staff #1 observed and acknowledged it was missing and stated a resident must have taken it out of the bathroom.
Plan of Correction:	THIS ISSUE HAS BEEN CORRECTED, AND WAS CORRECTED ON THE DAY OF INSPECTION, UNFORTUNATELY AFTER THE INSPECTOR?S DEPARTURE AND NOT AT THE EXACT MOMENT WHEN NOTICED BY THE INSPECTOR; STAFF/HOUSEKEEPING HAS BE REMINDED OF THE NEED TO ENSURE THAT THE BATHROOMS HAVE THE NECESSARY ITEMS AT ALL TIMES; TO ALSO TO BE CHECKED AT THE END OF THE DAY
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview with staff, the facility failed to ensure the fire drills included the identity of the person conducting the drill, the method used for notification of the drill; the number of staff participating; any special conditions simulated; weather conditions; and problems encountered, if any. Evidence: 1. The fire drills in the licensure period from June to December 2022 did not document the identity of the person conducting the drill, the method used for notification of the drill; the number of staff participating; any special conditions simulated; weather conditions; and problems encountered (if any). 2. Staff #1 acknowledged during interview.
Plan of Correction:	FIRE DRILL HAS BEEN DOCUMENTED AS REQUIRED; SEE ATTACHED DOCUMENT BELOW
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview with staff, 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?s date of hire is 10-26-2020; however, there was no criminal history record report for Staff #2. 2. Staff #3?s date of hire is 10-01-2020; however; there was no criminal history record report for Staff #3.
Plan of Correction:	ALL CRIMINAL HISTORY REPORTS HAVE BEEN ORDERED AS OF JAN 12, 2023; ANTICIPATED RETURN BY END OF FEBRUARY OR SOONER