VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hidden Treasures Residential Living
201 Dodge Street
Stuarts draft, VA 24477
(540) 490-1093

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: May 15, 2024

Complaint Related: No

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: 5/15/2024 8:45am-4:00pm 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. the following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, fire drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: N/A 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. 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. 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at jessica.gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1120-B
Description:	Based on direct observations and staff interviews, the facility failed to ensure that there is at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day. Evidence: 1. Two licensing staff present in the facility did not observe any activities being performed. 2. Staff 2 stated there were no scheduled activities for the day.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-120-A
Description:	Based on record review and staff interview, the facility failed to ensure the required orientation and training are completed within the first seven working days of employment. Evidence: 1. Following the record review for staff 1 (hire date 5/5/2023) and Staff 4 (hire date 9/14/2023) there was no documentation of orientation or training within the first seven working days of employment. 2. Staff 2 stated ?It wasn?t done?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-A
Description:	Based on record review and staff interviews the facility failed to ensure all direct care staff shall attend at least 14 hours of training annually. Evidence: 1. Following record review, staff 1 (hire date 5/5/2023), Staff 2 (no hire date present or known), Staff 3 (hire date 10/19/2021) and Staff 5 (hire date 7/12/2022), have no documentation of annual training. 2. Staff 3 stated in an interview, ?I don?t have the required training?.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person annually submit the results of a Tuberculosis risk assessment. Evidence: 1. Following record review for staff 1 (hire date 5/5/2023) Staff 2 (no hire date present or known), staff 3 (hire date 10/19/2021), Staff 5 (hire date 7/12/2022), there was no documentation of an annual tuberculosis risk assessment. 2. Staff 2 stated ?they weren?t done?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and staff interview, the facility failed to ensure each direct care staff member shall maintain current certification in first aid. Evidence: 1. Following record review, staff 2 does not have documentation of a certification in first aid. 2. Staff 2 stated ?I haven?t taken that?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-C
Description:	Based on direct observation and staff interview, the facility failed to ensure a listing of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) shall be posted in the facility. Evidence: 1. During the facility tour, there was no list present of staff with current first aid or CPR. 2. Staff 2 stated ?We don?t have that?.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
Description:	Based on record review and staff interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. During record review, the current staff schedule present on 5/15/2024 reflected only 4/26/2024 - 05/09/2024. 2. Staff 2 stated ?there is no schedule for 5/10/2024 - 5/15/2024?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: 1. Resident 3 admitted 02/29/2024 and Resident 5 admitted 5/1/2024 had no physical examinations present in the resident record. 2. Staff 2 stated ?We don?t have them?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and staff interview, the facility failed to ensure all residents are assessed using the uniform assessment instrument (UAI) at least annually. Evidence: 1.Resident 2 admitted 7/21/2022, did not have documentation of a UAI completed annually. 2. Staff 2 stated ?We don?t have it?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident 3 admitted 02/29/2024, does not have an individualized service plan present in resident record. Resident 5 admitted 5/1/2024 does not have an individualized service plan present in resident record. Staff 2 stated ?We don?t have it?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-A
Description:	Based on record review and staff interviews, the facility failed to ensure health care oversight was provided every six months. Evidence: 1. Upon request the facility failed to provide documentation of the completion of healthcare oversight. 2. Staff 3 stated ?that hasn?t been done?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-520-I
Description:	Based on record review and staff interviews, the facility failed to ensure there is a written schedule of activities. Evidence: 1. Upon request the facility failed to provide a written schedule of activities. 2. Staff 2 stated ?the binder with the activity calendars got really dirty and thrown away?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident and each staff person. Evidence: 1. Upon request, the facility did not provide documentation that the annual review of rights and responsibilities of residents in assisted living facilities had been conducted with staff and residents. 2. Staff 2 stated ?we don?t have that?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-E
Description:	Based on staff interview, the facility failed to retain resident records at the facility. Evidence: 1. Resident 6, with no documented admission date, did not have a resident record present at the facility on 5/15/24. 2. Staff 2 stated ?I don't know the admission date? and ?the chart isn?t here and may be in staff 3?s car"
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on direct observations during the facility tour and staff interviews, the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice. Evidence: 1. Two licensing staff observed during the facility tour an unlocked closet in the common area containing an unlocked medication cart with medications unsecured on the shelves accessible to residents. 2. Staff 2 stated ?The closet is unlocked because I don?t have the keys to lock it? 3. Staff 3 stated ?A previous employee has the med cart keys and we are unable to lock the cart, so it stays in the closet? 4. Photo evidence taken
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-690-A
Description:	Based on record review and staff interview, the facility failed to ensure an annual review of all the medications of the resident performed by a licensed health care professional. Evidence: 1. Upon request, the facility failed to provide documentation of a completed annual medication review. 2. Staff 3 stated ?It hasn?t been done?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area. Evidence: 1. Two licensing staff observed two unlocked closets were located in a common area accessible to residents. 2. One unlocked closet contained multiple bottles of bleach and the second closet contained bleach and other cleaning chemicals. 3. Photo evidence taken.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-B
Description:	Based on direct observation, the facility failed to ensure the facility is free from foul, stale, and musty odors. Evidence: 1. Upon entering the facility, two licensing staff observed a foul odor. 2. Two licensing staff observed a foul odor throughout through out the facility during the building tour.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Description:	Based on direct observation during a tour of the facility, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1. Two licensing staff observed the laundry room closet door unsecured to the wall and leaning against the wall next to the laundry room. 2. Two licensing staff observed in Resident 2?s room, window and door coverings broken and in poor condition. 3. Photo evidence taken.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-950-E
Description:	Based on record review and staff interview, the facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and Volunteers. Evidence: 1. Upon request, the facility did not provide documentation that emergency preparedness plan for orientation and semi-annual review had been conducted. 2. Staff 2 stated ?We haven?t done it.?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-970-A
Description:	Based on record review and staff interviews, the facility failed to ensure 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: 1. The fire drill log for 2023 documented fire drills for March, May, June and July. There were no fire drills documented as conducted for January, February, April, August, September, October, or December. 2.The fire drill log completed for 2024 included January. There were no fire drills documented as conducted for February, March, or April. 3.Staff 2 stated that they didn?t have them.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-990-C
Description:	Based on record review and staff interview, 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: 1. Upon request, the facility did not provide documentation that staff participated in resident emergency exercises. 2. Staff 2 stated, ?We don?t have any?.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-30-B
Description:	Based on record review and staff interview, the facility failed to ensure the sworn statement or affirmation was completed for all applicants for employment. Evidence: 1. Following record review, there was no sworn statement present for staff 1 (hire date 5/5/2023), and no date of completion present on the form for staff 2 (no hire date present or known), and staff 4 (hire date 9/14/2023). 2. Staff 2 stated ?I don?t know where there are?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and staff interviews, the facility failed to ensure that the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Following record review for staff 1 (hire date 5/5/2023), Staff 2 (no hire date present or known), or Staff 4 (hire date 9/14/2023), there were no criminal history reports present. 2. Staff 2 stated ?I don?t know where there are?
Plan of Correction:	Not available online. Contact Inspector for more information.