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: Dec. 14, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

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: 12-14-23 from 12:10 p.m.- 1:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11-27-23 regarding allegations in the area(s) of: resident care and building and grounds. Number of residents present at the facility at the beginning of the inspection: 118 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also 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 #:	22VAC40-73-450-H
Description:	Based on a review of the identified resident?s Individualized Service Plan (ISP), the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident. Evidence: Resident #1?s ISP dated 12-8-23 indicates that the resident needs assistance with ?toileting and incontinence care 3 x every day and as needed? as well as ?meal escort assistance 3 x every day-PA to assist resident with escorts to meals by reminding her of the time for meals.? However, based on the facility?s self-report and statements from the administrator and director of wellness, the PA failed to provide assistance such that the resident missed a meal and did not receive incontinent care for an extended period on 11-25-23.
Plan of Correction:	The facility will continue to provide three nutritional meals for all residents. Direct care staff to round and ensure all residents are escorted to the dining room if such service is required in the resident?s individual service plan. Charge nurses to ensure that residents have had their meals and care staff has documented meal attendance as required by individual service plans. The Wellness Director (and/or designee) will review on daily basis to ensure compliance. The Executive Director will sample five (5) residents? charts to ensure documentation is completed per above. Will repeat for 90 days.
Standard #:	22VAC40-73-460-B
Description:	Based on a review of the facility?s call bell history for Resident # 1 for the month of November 2023, the facility failed to provide prompt response by staff to the residents' needs to ensure that care provision and service delivery were resident care centered to the maximum extent. Evidence: -The facility?s Call History Log for Resident # 1 indicates wait times for staff response for the following: 10-20 minutes on six instances on 11-25-23. -On 11-24-23 the call history log for Resident # 1 indicates three instances of wait times of 10-20 minutes, four instances of 21-30 minutes, and two instances of a 3 hr. wait time.
Plan of Correction:	Charge nurses to ensure that residents have had their meals and care staff has documented meal attendance as required by individual service plans. The Wellness Director (and/or designee) will review on daily basis to ensure compliance. The Executive Director will sample five (5) residents? charts to ensure documentation is completed per above. Will repeat for 90 days.
Standard #:	22VAC40-73-460-H
Description:	Based on a self-report from the facility dated 11-25-23, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: The activities of daily living to include bowel control, bladder control; and eating/feeding. Evidence: -A self-report received from the facility dated 11-25-23 stated, ?Personal Assistant (PA) failed to complete morning ADLs as well as failure to provide care set forth in the resident?s care plan of care, causing the resident to miss a meal and go an extended period without incontinent care.? -The facility?s administrator and director of wellness confirmed that the agency personal assistant who was assigned to Resident # 1 was relieved of her duties, removed from the facility, and placed on a do not return status due to failure to provide care to the resident according to resident?s plan of care.
Plan of Correction:	The Facility will ensure that care is provided to each resident as necessary so that their needs are met pursuant to individual service plans. The Charge Nurse will ensure that care is provided to the residents and documented pursuant to individual service plans. The Wellness Director will ensure that all residents? care is documented daily. The Executive Director will sample five (5) residents? charts to ensure documentation is completed per above. Will repeat for 90 days.