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, 2024

Complaint Related: Yes

Areas Reviewed:

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

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: 12-14-23 from 9:45 a.m.-12:10 p.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 11-30-23 regarding allegations in the area(s) of: resident care 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 Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s); area(s) of non-compliance with standard(s) or law were: resident care and building and grounds. A violation notice was issued; any violation(s) not related to the (complaint(s)/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 #:	22VAC40-73-530-C
Complaint related:	Yes
Description:	Based on a complaint received, as well as interviews with facility staff, the facility failed to ensure that they provide freedom of movement for the residents to their personal spaces. The facility shall not lock residents out of or inside their rooms. Evidence: Staff #1 and Staff #2 stated that the rooms of some memory care residents are locked to prevent residents from wandering into other residents? rooms on the unit. Staff #1 and Staff #2 stated that staff open the residents? room doors with keys when they observe the residents returning to their room doors. Staff #1 and Staff #2 stated that many of the residents? family members request that their loved ones door be locked to prevent other residents from wandering into their rooms.
Plan of Correction:	The charge nurse (and/or a designee) will ensure that all doors are unlocked and remain unlocked in Memory Care. The Director of Wellness (and/or a designee) will re-educate all care staff on keeping resident doors unlocked in Memory Care. The Executive Director (and/or a designee) will monitor the adherence to this requirement. Families of Memory Care residents will be notified of the Department?s decision.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on a review of the facility documentation, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. Evidence: There was no documentation in the 2 Hour Rounds log for Resident # 1 for November 2023 from 11-18-23 until 11-20-23 and from 11-21-23 until 11-26-23 and no documentation for 11-27-23.
Plan of Correction:	The Facility will re-educate all direct care staff on rounding and care documentation. The Director of Wellness (and/or a designee) will ensure that rounding documentation is reviewed daily and prior to care staff shift changes. For a period of 90 days, the Executive Director will also make a monthly review of rounding documentation of at least five (5) residents to ensure compliance.