VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Friendship Salem Terrace
1851 Harrogate Drive
Salem, VA 24153
(540) 444-0343

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Dec. 13, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Technical assistance was provided regarding medication management plan components, maintenance of resident care plans, and documentation of physical plant maintenance to ensure a thorough understanding of the regulations.

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: 12/13/2022 from 09:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on an audit of medication carts and resident record review, the facility failed to implement a section of its infection control policy. EVIDENCE: 1. The facility?s infection control program, updated 08/25/2022, in reference to blood glucose monitoring, indicated that ?each glucometer must be labeled with the resident?s name on the glucometer itself?. 2. The record for resident 4 contained a physician?s order, dated 11/04/2022, that the resident?s blood glucose is to be checked every Monday and Thursday at 06:00 AM for diabetes management. During an audit of the first-floor medication cart, it was noted by collateral 1 and staff 2 that the glucometer for resident 4 did not contain the name of the resident on the glucometer itself.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on an audit of medication carts and resident record review, the facility failed to implement a section of its infection control policy. Resident 4 will have the glucometer properly labeled. 100% of Nursing staff will be trained on Diabetic Management and Infection Control Policies pertaining to proper management of the resident?s Glucometers.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At 09:15 AM, collateral 1 noted a container of Act mouth wash and Suave volumizing mousse were on the bathroom sink in resident 5?s room. Both containers contained a statement to ?keep out of reach of children?. 2. At 09:19 AM, collateral 1 noted a container of Tresemme hair spray was on the bathroom sink in resident 1?s room. The container contained a statement to ?keep out of reach of children?. 3. At 09:25 AM, collateral 1 noted a container of McKesson shaving cream on the bedside table in resident 6?s room. The container contained a statement to ?keep out of reach of children?. 4. At 09:41 AM, LI observed a light brown round pill with ?G 2? displayed on it. This was found in the floor of the library, located on the second floor of the facility. 5. At 09:42 AM, collateral 1 noted that the door to the resident laundry room located in the facility?s safe, secure unit was unlocked and the LI observed a container of All laundry detergent in the bottom of a cabinet to the left of the laundry room.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on observation during a tour of the building, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. 100% of staff will be trained on proper storage of hazardous materials within common areas and / or resident rooms. This training will include all levels of care with Independent Living, Assisted Living and Memory Care residents.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure all furnishings, including furniture, were kept clean. EVIDENCE: At 09:16AM, collateral 1 noted that the box spring of the bed in resident 5?s room contained a medium sized area of a brown substance.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on observation, the facility failed to ensure all furnishings, including furniture, were kept clean. Resident 5 bedding will be cleaned and protective covering added to the box spring / mattress. 100% of all staff will be trained on ensuring all furnishings are kept clean and soiled items are cleaned when identified.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure that a sworn disclosure statement is completed for all applicants for employment. EVIDENCE: The record for resident 5 contained a hire date of 09/14/2022; however, the sworn disclosure statement on file was dated 02/18/2022.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review, the facility failed to ensure that a sworn disclosure statement is completed for all applicants for employment. We have modified our employee transfer process to the following: The manger submits a position change form in our HRIS system and HR confirms and approves once the employee completes all required regulatory paperwork.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to ensure that a criminal history record report is obtained on or prior to the 30th day of employment for each employee. EVIDENCE: The record for resident 5 contained a hire date of 09/14/2022; however, the criminal history record reports on file were 02/16/2022 and 12/13/2022.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services Based on record review, the facility failed to ensure that a criminal history record report is obtained on or prior to the 30th day of employment for each employee. We have modified our employee transfer process to the following: The manger submits a position change form in our HRIS system and HR confirms and approves once the employee completes all required regulatory paperwork.