VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Crossings at Ironbridge
6701 Ironbridge Parkway
Chester, VA 23831
(804) 748-7000

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: June 8, 2023

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

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: 6-8-23 from 10:55 a.m.- 7:05 p.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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit, emergency food supply, medication pass, physician?s orders, medication administration records. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: The record for Staff # 2 (date of hire: 3-27-23) did not contain first aid certification.
Plan of Correction:	A first aid and CPR training has been scheduled for 6/22/2023 for all staff who has expired first aid or CPR training. On 6/9/2023 the Administrator retrained the Director of Wellness on all Nursing team members are to at least be First Aid Trained within 60 days of start date of employment.
Standard #:	22VAC40-73-940-A
Description:	Based on a review of facility documentation the facility failed to ensure that it shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: The facility?s last fire inspection was dated 2-17-22.
Plan of Correction:	The Fire Inspection was completed on 6/13/2023 with no violations. Moving forward Plant Operation Director will ensure that the inspection has been scheduled in a timely manner and the Administrator will follow up. On 6/13/2023 The Fire Marshall gave his direct contact information to ensure the date is locked in and so the administrator can reach out directly.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure the semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. Evidence: The facility did not have documentation that the emergency preparedness and response plan (dated 1-14-23 by the administrator) was reviewed with all staff, residents, and volunteers.
Plan of Correction:	The administrator will ensure that the Emergency Preparedness and response plan is reviewed by all staff, residents, and volunteers semi-annually and documented. The start date of the training will be 6/14/2023 and will be completed by 6/30/2023 for all staff, residents, and volunteers.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of facility documentation the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: The facility had no documented fire and emergency evacuation drills from 12-30-22 until 4-20-23.
Plan of Correction:	Fire Drill is scheduled for 6/15/2023 for night shift and 6/16/2023 for day shift and maintenance assistant has been retrained on fire drills, regarding they are to be conducted monthly, on alternating shifts to ensure all shifts are participating in the fire drills.
Standard #:	22VAC40-73-980-H
Description:	Based on observation the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water and that at least 48 hours of the supply must be on site at any given time, of which the facility's rotating stock may be used. Evidence: The facility did not have an emergency water supply on site.
Plan of Correction:	Emergency Water was ordered and delivered on 6/14/2023. Administrator met with Director of Food and Beverage on 6/9/2023 to retrain on providing the emergency supply to always include food and water on site in case of an emergency.
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records the facility failed to ensure that a criminal history record report from the State Police shall be obtained prior to the 30th day of employment. Evidence: -The record for Staff # 2 (date of hire: 3-27-23) contained a criminal history record report that was not from the Virginia State Police, but from a source called JDP. -The record for Staff # 1 (date of hire: 4-20-23) did not contain the results of a criminal history record report. -The record for Staff # 5 (date of hire: 3-7-23) reviewed with all new hires did not contain the results of a criminal history record report.
Plan of Correction:	Going forward as of 6/8/2023 the administrator will ensure that all background checks are obtained from the Virginia State Police department and that all background reports are printed/placed in the staff member?s file.