The Haven Assisted Living @ Studley
7436 Studley Road
Mechanicsville, VA 23116
(804) 779-4847
Current Inspector: Kimberly Davis (804) 662-7578
Inspection Date: April 17, 2024 and April 25, 2024
Complaint Related: No
- Areas Reviewed:
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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:
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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: 4-17-24 from 10:25 a.m.-12:15 p.m. and 4-25-24 from 7:40 a.m.-8:40 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: 6
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Additional Comments/Discussion: The following items were also reviewed/observed: facility documentation, facility postings, first aid kit, medication pass, physician?s orders, Medication Administration Records (MARs).
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:
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Standard #: 22VAC40-73-680-D Description: Based on observation during a medication pass, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions.
Evidence:
The physician?s orders listed on the Medication Administration Record for April 2024 for med pass Resident # 2 indicated ?Acetaminophen Extra Strength, Take 2 tablets (1000mg) by mouth at 8 am, 2 pm, and 8 pm for pain.? However, the resident was administered two 650 mg Tylenol (Acetaminophen) to equal 1300mg. Staff # 1 stated that the resident?s ?family brought the wrong one.?Plan of Correction: Administrator contacted the family to ensure the correctTylenol would be provided. Education was provided to the family concerning the importance of the medication matching the doctors orders. Family will now provide the correct strength
Tylenol moving forward.
Standard #: 22VAC40-73-710-C Description: Based on observation during med pass, the facility failed to ensure that if a restraint is used, it must:
1.Be imposed in accordance with a physician's written order that specifies the condition, circumstances, and duration under which the restraint is to be used and
2.Not be ordered on a standing, blanket, or "as needed" (PRN) basis.
Evidence:
The record for Resident # 1, who was observed sitting in a geri chair during med pass, did not contain a signed physician?s written order.Plan of Correction: Administrator ensured hospice provided orders for DME provided to their patients. Order to be provided by hospice at the following visit per discussion with hospice nurse.
Standard #: 22VAC40-73-870-A Description: Based on observation during a tour of the facility, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence:
The floor tile was damaged with several areas of missing tile. Photographic evidence was taken.Plan of Correction: Administrator will ensure floors and tiles are replaced in a timely manner, an appointment for replacement has been placed to have the floors done within the month.
Standard #: 22VAC40-80-120-E-2 Description: Based on observation the facility failed to ensure that the findings of the most recent inspection of the facility were posted.
Evidence:
The facility?s most recent violation notice was not posted.Plan of Correction: Administrator reprinted and posted previous inspection report. Same day as violation and for the future, administrator will ensure a copy is placed each time there is an inspection.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.