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: Jan. 23, 2024

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2024 from 08:45 AM until 03:00 PM 01/24/2024 from 08:00 AM until 03:00 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 #:	22VAC40-73-325-C
Description:	Based on record review and staff interview, the facility failed to ensure that if a resident who meets the criteria for assisted living care falls, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. EVIDENCE: 1. The individualized service plan (ISP) for resident 7, dated 10/06/2023, contains documentation that a fall occurred on 11/29/2023 while she was pacing throughout the unit, resulting in hitting her head and a hematoma on the left eyebrow. Per physician progress notes, dated 12/05/2023, the resident was transported and treated at the ER and returned to the facility as a result of the fall on 11/29. 2. An interview with staff 6 revealed that the facility?s documented interventions after this fall were that first aid was provided, the MD was notified, and emergency assistance was obtained for the resident; however, staff 6 also added that there were no further interventions initiated to prevent or reduce risk of subsequent falls.
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 and staff interview, the facility failed to ensure that if a resident who meets the criteria for assisted living care falls, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. All staff will be in-serviced on the following standard to include recommendations of various interventions that are appropriate following specific incidents. All resident records will be audited by leadership post incident record to ensure completion and proper interventions are in place to prevent subsequent incidents.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) shall include a description of identified needs based on all sources, including the uniform assessment instrument (UAI). EVIDENCE: 1. The UAI for resident 4, dated 01/05/2024, indicates that the resident requires mechanical assistance and physical assistance with wheeling; however, the ISP for resident 4, dated 01/05/2024, does not identify the resident?s need for wheeling assistance. 2. Interview with staff 6 revealed that the UAI for resident 4 is correct and that the resident would require the physical assistance of staff pushing her wheelchair if outside of the community. 3. The UAI for resident 4 also indicates that the resident displays Abusive/Aggressive/Disruptive behaviors less than weekly; however, the resident?s ISP does not identify any behavioral needs for resident 4. 4. Interview with staff 6 revealed that the resident?s UAI is correct, and that the resident has displayed infrequent disruptive and aggressive behaviors.
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 and staff interview, the facility failed to ensure that the individualized service plan (ISP) shall include a description of identified needs based on all sources, including the uniform assessment instrument (UAI). The Facility will complete a 100% audit of all resident ISP?s to ensure accuracy of all identified care needs provided on the most recent uniform assessment instrument (UAI). All staff working with UAI and ISP completion will be in-serviced to ensure care needs are identified, reflected accurately and updated timely.