VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Valley ALF Operator LLC
940 East Lee Hwy
Chilhowie, VA 24319

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Feb. 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

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: 2/08/2023 Begin: 10:00am End: 3:11pm 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: 24 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on resident record review, the facility failed to provided the most up to date disclosure form required by the department. EVIDENCE: 1. Resident #2 was admitted on 12/13/2022; Resident #3 was admitted on 01/30/2022; Resident #4 was admitted on 10/17/2022; Resident #5 was admitted on 10/01/2021. None of the above-mentioned residents had most up to date disclosure issued by the Department.
Plan of Correction:	Most up to date Disclosure form has been added to admissions packet. Facility staff will be provided education regarding use of up to date disclosure forms. Unit manager and/or designee will audit all new admission packets for 3 months to ensure compliance. [sic]
Standard #:	22VAC40-73-260-C
Description:	Based on staff interviews and observations made during the tour of the building, the facility failed to have a listing of all staff with current certification in first aid or CPR posted in the facility and readily available to all staff at all times. EVIDENCE: 1. The LI was unable to locate the list of staff certified in first aid and CPR posted in the facility during the 02/08/2023 inspection. 2. According to Staff #4 a current list of staff certified in first aid and CPR is not posted in the facility at this time.
Plan of Correction:	A list of staff certified in first aid and CPR will be posted in facility at all times and will be updated with all new staff upon hire. Facility staff will be provided education regarding posting current CPR and first aid certified staff members. Unit manager and/or designee will audit for compliance daily x 14 days then weekly for 3 months. [sic]
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to have a valid physician?s order for one resident that included the oxygen source such as compressed gas or concentrator. EVIDENCE: 1. Resident # 5 has a physician?s order dated 02/02/2023. The source of the oxygen is not defined on the order for Resident #5.
Plan of Correction:	All oxygen orders will be corrected by physician or designee and indicate source used: compressed gas or concentrator. Facility staff will be provided education on correct orders to include source used for oxygen delivery. Unit manager and/or designee will audit compliance daily x 14 days then weekly for 3 months. [sic]
Standard #:	22VAC40-73-750-E
Description:	Based on observations made during the tour of the building, the facility failed to have sufficient bed linens in good repair so that residents always have clean pillowcases. EVIDENCE: 1. The pillowcase for Resident #8 had brown stains on it over an area approximately 8 by 6 inches. Per Staff #4, 2. Resident # 8 recently had her hair colored which resulted in the stained pillowcase.
Plan of Correction:	Bed linens will be changed weekly and as needed or soiled. Facility staff will be educated on frequency and need to change linens when soiled. Unit manager and/or designee will audit for compliance daily x 14 days then weekly for 2 months. [sic]
Standard #:	22VAC40-73-860-J
Description:	Based on observations made during the tour of the building, the facility failed to store cleaning supplies or other hazardous materials so they are not accessible to residents with serious cognitive impairment. EVIDENCE: 1. Resident # 8 has a diagnosis of dementia listed in the significant medical history section of the physical examination report; the LI observed a package of FitRight Aloe Personal Cleansing Cloths in the bathroom for resident # 8, with a warning to store out of reach of children. 2. Resident # 9 has a diagnosis of dementia listed in the significant medical history section of the physical examination report; the LI observed a package of FitRight Aloe Personal Cleansing Cloths in the bathroom for Resident #9, with a warning to store out of reach of children.
Plan of Correction:	All residents? rooms with a diagnosis of dementia will be free from any harmful substance, cleaning supplies including products with labels warning to store out of reach of children. Facility will provide education to staff regarding harmful substances and chemicals as well as packages label to keep out of reach of children. Unit manager and/or designee will audit for compliance daily x 14 days then weekly x 3 months. [sic]
Standard #:	22VAC40-73-880-B
Description:	Based on observations made during the tour of the building, the facility failed to maintain a temperature of at least 72 degrees Fahrenheit in all areas used by residents during hours when residents are usually awake. EVIDENCE: 1. The thermostat in the hallway beside resident room # 205 indicated it was 68 degrees Fahrenheit at 11:49 a.m. on the date of inspection, 02/08/2023. The same thermostat indicated in was 69 degrees Fahrenheit at 2:30pm on the same date
Plan of Correction:	Thermostats in all areas will be set between 72 degrees and 80 degrees to ensure resident comfort. Facility staff will be educated regarding temperature control ranges between 72 degrees and 80 degrees. Unit manager and/or designee will audit for compliance daily x 14 days then weekly x 3 months. [sic]