VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hanover Manor
809/811 Thompson Street
Ashland, VA 23005
(804) 368-0110

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: April 2, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-2-24 from 9:00 a.m.-11:15 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3-8-24 regarding allegations in the area(s) of: resident care and staffing. Number of residents present at the facility at the beginning of the inspection: 37 Number of resident records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). 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 # 2 (admit date: 3-29-18) contained a UAI last dated 3-29-23.
Plan of Correction:	The UAI that was due to be completed on 03-29-2024 was completed on 04-02-2024. Monthly audits will be performed by both Directors of Nursing to ensure that all UAIs and ISPs due for that month are completed timely.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of resident records the facility failed to ensure that Individualized service plans (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 # 2 contained an ISP last dated 3-29-23.
Plan of Correction:	The ISP that was due to be completed on 03-29-2024was completed on 04-02-2024. Monthly audits will be performed by both Directors of Nursing to ensure that all UAIs and ISPs due for that month are completed timely.