VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Lodge at Old Trail
330 Claremont Lane
Crozet, VA 22932
(434) 823-9100

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: May 8, 2023 and May 16, 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-8-23 from 11:00 a.m.- 5:00 p.m. and 5-16-23 from 10:20 a.m.- 1:30 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit, emergency food and water, lunch meal/menu, 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:

Standard #:	22VAC40-73-120-A
Description:	Based on a review of staff records the facility failed to ensure that the orientation and training required shall occur within the first seven working days of employment. Evidence: The record for Staff # 4 (date of hire: 4-6-22) did not contain documentation of staff orientation and initial training.
Plan of Correction:	Staff #4 signed and acknowledged being trained and receiving an orientation when she was rehired. The Administrative Services Director has created a system for all rehires to be treated as new hires with all new documentation.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: -The record for Staff # 3 (date of hire: 2-27-23) did not contain first aid certification. -The record for Staff # 4 (date of hire: 4-6-22) contained first aid certification that expired in January 2023.
Plan of Correction:	Staff #3 provided a copy of her certification which expires August 11, 2023. Staff #4 obtained her first aid certificate on May 16, 2023. The H&W director and the Administrative Services Director have created a system to track the obtainment of required documents.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to ensure that the UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: -The record for Resident # 3 (admit date: 3-11-21) contained a UAI last dated 3-29-23. -The record for Resident # 4 (admit date: 1-15-22) contained a UAI last dated 2-7-23.
Plan of Correction:	Both residents have a current UAI as of June 6, 2023.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records the facility failed to ensure that the ISP contained a written description all identified needs based on the UAI. Evidence: The record for Resident # 9 (admit date: 5-5-14) contained an ISP created on 7-11-22 that did not address the following needs identified on the resident?s UAI dated 6-30-22: bladder incontinence (weekly or more), dressing (physical assistance), and orientation (disoriented-some spheres, some of the time.)
Plan of Correction:	Resident #9?s ISP was updated to include catheter rather than incontinence, assistance with dressing, and address his disorientation.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: -The record for Resident # 8 (admit date 11-11-22) contained an ISP created on 11-28-22 that was not signed or dated by the licensee, administrator, or his designee. -The record for Resident # 10 (admit date: 10-16-2020) contained an ISP created on 10-12-22 that was not signed or dated at all. -The record for Resident # 5 (admit date: 8-18-14) contained an ISP created on 8-11-22 that was not signed or dated at all.
Plan of Correction:	Resident #8?s ISP was signed by the Health and Wellness Director. Resident #10?s ISP was signed by the resident and Health and Wellness Director. Resident #5?s ISP was signed by the resident?s responsible party and Health and Wellness Director. The Health and Wellness Director has created a system that ensures the documents are reviewed and signed after being finalized.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that ISP shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: -The record for Resident # 3 (admit date: 3-11-21) contained an ISP last dated 3-29-23. -The record for Resident # 4 (admit date: 1-15-22) contained an ISP last dated 1-31-23.
Plan of Correction:	Both residents have a current ISP as of May 16, 2023.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person. Evidence of this review shall be the staff person?s written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. Evidence: The record for Staff # 4 (date of hire: 4-6-22) did not contain written acknowledgment of an annual review of resident rights.
Plan of Correction:	Staff #4 reviewed and signed the resident?s rights document. The Administrative Services Director has created a system for all rehires to be treated as new hires with all new documentation.
Standard #:	22VAC40-73-580-A
Description:	Based on a review of facility documentation the facility failed to ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: The facility?s last health inspection was dated 3-22-22.
Plan of Correction:	The Dining Services Director had an appointment for a health inspection scheduled. The health inspector came on June 2, 2023. The Dining Services Director has been given instructions from the Health Department on how to request the inspection.
Standard #:	22VAC40-73-990-C
Description:	Based on an interview with the administrator the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The facility did not have documentation of a practice exercise for a resident emergency.
Plan of Correction:	A safety emergency drill occurred on May 26, 2023 for first shift. An elopement drill is scheduled for June 8, 2023 2nd shift. A resident emergency transport to the hospital drill is scheduled for June 9, 2023 for 3rd shift.