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: June 25, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

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: An onsite inspection was conducted on 04/05/24 after a complaint was received alleging residents of facility were being left alone at the facility without employees of the facility being present. The Acknowledgement of Inspection form was signed and left at the facility. The VDSS Division of Licensing was contacted on 04/02/24 regarding allegations in the area(s) of: Personnel, staffing and supervision, and resident care and related services. Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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. Should you have any questions, please contact Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-190-A
Complaint related:	No
Description:	Based on observations and interviews, it was determined that the facility did not ensure that when the administrator, the designated assistant, or the manager is not awake and on duty on the premises, a designated direct care staff member in charge shall be on the premises. Evidence: 1) On April 05, 2024, at 9:00 AM, Licensing Inspectors arrived at the facility and discovered two residents were alone in the facility with no staff present. 2) Employee #1 confirmed that on April 02, 2024, and April 05, 2024, two residents were left alone in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Complaint related:	No
Description:	Based on a review of employee records, it was determined that the facility did not ensure that employees submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form, within seven days prior to coming into contact with residents. Evidence: 1) A review of employee #3?s file did not contain the results of a risk assessment, documenting the absence of tuberculosis in a communicable form. 2) Employee #1 reviewed the record for employee #3 and was unable to provide documentation of a completed TB risk assessment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-B
Complaint related:	No
Description:	Based on observations and interviews, it was determined that the facility did not maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs, and any identified special needs for the residents in care. Evidence: 1) The written staffing plan for the facility did not specify the type and number of direct care staff required to meet the day-to-day needs of the residents. 2) The written staffing plan for the facility only listed the first names of the current employees. There was no identification of what their roles and responsibilities are. 3) The written staffing plan for the facility did not specify which employees were scheduled to work which hours; nor did it specify what days of the week they were scheduled to work.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-C
Complaint related:	No
Description:	Based on observations and interviews, it was determined that the facility did not maintain an adequate number of staff persons at the facility at all times to implement the fire and emergency evacuation plan. Evidence: 1) On April 02, 2024, and April 05, 2024, two residents were left alone in the facility without any employees present. 2) Employee #1 confirmed that on April 02, 2024, and April 05, 2024, two residents were left alone in the facility with no staff present to assist with the fire and emergency evacuation plan.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-280-D
Complaint related:	No
Description:	Based on observations and interviews, it was determined that the facility did not ensure at least one direct care staff member was always on-duty when at least one resident is present. Evidence: 1) On April 02, 2024, and April 05, 2024, two residents were left alone in the facility without any employees present. 2) Employee #1 confirmed that on April 02, 2024, and April 05, 2024, two residents were left alone in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record reviews and interviews, it was determined that the facility did not ensure that within 30 days preceding admission, a resident shall have a physical examination by an independent physician, that includes a statement whether the individual is, or is not, capable of self- administering medication. Evidence: 1) Resident #1 was observed self-administering medication. 2) The physical examination report in resident #1?s file did not include a statement clarifying if the resident is able to self-administer their medication. 3) Employee #1 confirmed that resident #1 does self-administer medication #1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviews, it was determined that the facility did not ensure that an updated uniform assessment instrument (UAI) was completed at least annually to determine whether a resident's needs can continue to be met by the facility, and whether continued placement in the facility is in the best interest of the resident. Evidence: 1) A review of resident #1?s record did not contain an annually updated uniform assessment instrument (UAI). The last UAI for resident #1 was completed on January 12, 2023. 2) Employee #1 reviewed the record for resident#1 and was unable to provide documentation that the uniform assessment instrument (UAI) had been updated annually.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observations and interviews, it was determined that the facility did not ensure resident medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1) Small plastic cups labeled with each resident?s name were observed on one of the dining area tables. 2) Employee #1 stated employee #2 (registered medication aide) places the residents? medications in these cups. These cups are then placed on the dining room table. 3) Employee #1 stated employee #2 is not always present when the resident?s take their medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on record reviews, it was determined that the facility did not document on a medication administration record (MAR) medications administered to residents. Evidence: 1) Employee #1 verified with employee #2 by phone during the inspection that all residents prescribed medications to be administered at 8:00 AM on April 05, 2024, were indeed given their medications. 2) Employee #1 reviewed the medication administration records (MAR) for the residents and confirmed the administration of medications had not been documented on the respective medication administration records (MAR).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observations, it was determined that the facility did not ensure that the furniture and showers, were kept clean and in good repair and condition. Evidence: 1) Dresser in one resident?s room missing front panel. 2) In the kitchen, an inoperable dishwasher was noted. 3) An inoperable microwave oven was observed in the kitchen. A sign affixed to the microwave stated the microwave was inoperable.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Complaint related:	No
Description:	Based on a review of three staff records, it was determined that the facility did not ensure that employees meet the requirements specified in the Regulation for Background Checks for Assisted Living Facilities. Evidence: 1) A review of the file for employee #3 did not contain the results of the required background screening. 2) Employee #1 reviewed the record for employee #3 and was unable to provide a state police criminal record check.
Plan of Correction:	Not available online. Contact Inspector for more information.