VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Blake at Charlottesville
250 Nichols Court
Charlottesville, VA 22901
(434) 973-7900

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Nov. 27, 2023 and Jan. 3, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: 11-27-23 from 10:10 a.m.- 2:45 p.m. and 1-3-24 from 10:05 a.m.-3:30 p.m. 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: 122 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, first aid kit, medication pass, physician?s orders, Medication Administration Records (MARs), and lunch meal/menu. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Staff # 3 (date of hire: 9-27-22) contained a TB screening last dated 11-21-22. -The record for Staff # 4 (date of hire:4-7-21) contained a TB screening last dated 11-10-22. -The record for Staff # 5 (date of hire: 10-12-21) contained a TB screening last dated 11-11-22.
Plan of Correction:	All direct staff personnel will have proof of tuberculosis screening in their records. All direct staff personnel records will be audited for compliance. The Director of Business Operations (and/or designee) will track and coordinate the completion of TB screening as needed. The Executive Director (and/or designee) will oversee said annual audit to ensure compliance.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to ensure that each resident?s 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 # 6 (admit date:8-31-22) contained a UAI last dated 9-22-22. -The record for Resident # 7 (admit date: 9-23-19) contained a UAI last dated 9-10-22.
Plan of Correction:	The Facility will ensure that the Uniform Assessment Instrument (UAI) is completed prior to admission, annually and whenever there is a significant change in the resident?s condition. UAI will be completed as they mature. The Wellness Director (and/or designee) will track and complete the UAI. The Wellness Director (and/or designee) will spot check monthly for three consecutive months.
Standard #:	22VAC40-73-450-E
Description:	Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: -The ISP for Resident # 4 (admit date: 9-5-23) was not signed or dated at all. -The ISP for Resident # 5 (admit date: 5-15-23) was not signed or dated at all. -The ISP for Resident # 9 (admit date: 9-5-19) was not signed or dated by the resident or his/her legal representative.
Plan of Correction:	The Facility will timely complete each Individualized Service Plan (ISP). 01/02/2024 Each ISP will be signed and dated by the licensee, administrator, or designee and by the resident or their legal representative. Director of Wellness and/or Assistant Director of Wellness will be responsible for reviewing and completing each ISP. The Executive Director will spot check five ISPs per month for compliance for three consecutive months.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that Individualized service plans 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 # 6 (admit date: 8-31-22) contained an ISP last dated 10-31-22. -The record for Resident # 7 (admit date: 9-23-19) contained an ISP last dated 11-5-22. -The ISP for Resident # 9 (admit date: 9-5-19) was last dated 8-3-22.
Plan of Correction:	The Facility will timely complete each Individualized Service Plan (ISP). Each ISP will be signed and dated by the licensee, administrator, or designee and by the resident or their legal representative at least every 12 months. Director of Wellness and/or Assistant Director of Wellness will be responsible for reviewing and completing each ISP. The Executive Director will spot check five ISPs per month for compliance for three consecutive months.
Standard #:	22VAC40-73-520-I
Description:	Based on observation of facility postings the facility failed to ensure that the current month's activity schedule shall be posted in a conspicuous location in the facility or otherwise be made available to residents and their families. Evidence: During a tour of the facility on 1-3-24, the licensing inspector observed that the activity schedule posted in the hallway on the first floor was for the month of December.
Plan of Correction:	The Facility will ensure that the activities calendar is updated in the middle of the current month and posted by the first day of each month. The Activity Director (and/or designee) will complete and post the calendar the first day of the month. The Executive Director (and/or designee) will monitor for compliance.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's record. Evidence: The record for Resident # 6 (admit date: 8-31-22) and Resident # 8 (admit date: 9-28-22) did not contain written acknowledgment of an annual review of the rights and responsibilities of residents in assisted living facilities.
Plan of Correction:	The Facility will review residents? rights annually with each resident or his/her legal representative. Evidence of this review will be maintained in the resident business records. The annual review will take place at the beginning of the month of November of each year. The Business office (and/or designee) will complete the annual requirement. The Executive Director will verify that all residents have signed the residents? rights for compliance.
Standard #:	22VAC40-73-610-B
Description:	Based on observation of facility postings the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: During a tour of the facility on 1-3-24, the licensing inspector observed that the menu posted in the main dining room was dated for the week of 12-17-23 through 12-23-23.
Plan of Correction:	The Facility will ensure that the activities calendar is updated in the middle of the current month and posted by the first day of each month. The Activity Director (and/or designee) will complete and post the calendar the first day of the month. The Executive Director (and/or designee) will monitor for compliance.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers.
Plan of Correction:	All direct staff personnel will have proof of tuberculosis screening in their records. All direct staff personnel records will be audited for compliance. The Director of Business Operations (and/or designee) will track and coordinate the completion of TB screening as needed. The Executive Director (and/or designee) will oversee said annual audit to ensure compliance.
Standard #:	22VAC40-73-980-C
Description:	Based on a review of the facility?s first aid kit the facility failed to ensure that first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: The facility did not have documentation of when the first aid kit was last checked.
Plan of Correction:	The Facility will have a first aid inspected monthly to ensure that all items are present and content is not expired. The Wellness Director (and/or designee) will check the first aid kit and sign off monthly. The Executive Director will verify that the inspection is completed.