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: June 17, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 6-17-24 from 12:35 p.m. ? 1:55 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 2-16-24 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 119 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s)of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on a review of the resident?s record the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall. Evidence: The record for Resident # 1 contained charting notes indicating that the resident had two falls in January 2023 on the following dates : 1-17-23 and 1-30-23. However, the resident?s record only contained one fall risk assessment updated 2-12-23.
Plan of Correction:	The Facility will ensure that all fall risk ratings are completed after each fall and at least annually. The Director of Wellness (and/or designee) will verify that the fall risk ratings are completed in a timely manner. The Executive Director will spot check during the monthly safety meetings to ensure compliance for three consecutive months.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on a review of the resident?s record the facility failed to ensure that the individualized service plan 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 dated 2-1-24 for Resident # 1 was not signed or dated at all.
Plan of Correction:	The Facility will complete each Individualized Service Plan (ISP) as required and on time. Each ISP will be signed and dated by the Facility?s Executive Director or Director of Wellness or an appropriate designee and by the resident or their legal representative. The Director of Wellness (and/or an appropriate designee) will be responsible for reviewing and completing all such ISPs. The Executive Director will spot check five ISPs each month for compliance for three consecutive months.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on a review of the resident?s record the facility failed to ensure that when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident's record. The date and time of occurrence, as well as the personnel involved shall be included in the documentation. 1. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention. If a resident refuses medical attention, the resident's physician shall be notified immediately. 2. A notation shall be made in the resident's record of such notice, including the date, time, caller, and person notified. Evidence: Facility progress notes for Resident # 1 for February 2024 noted that the resident tested positive for COVID-19 on 2-10-24. However, there was no documentation in the resident?s record to indicate that the facility had notified the resident?s next of kin of the resident testing positive for COVID, as there was no notation of the date, time, caller, and person notified by the facility.
Plan of Correction:	The Facility will reeducate staff to ensure that the attending medical provider, next of kin, legal representative, and designated contact person are notified of any change of condition and/or illness. In addition, the Facility will reeducate staff to ensure that such notification is documented. The Director of Wellness (and/or an appropriate designee) will complete the reeducation and monitor notification. The Executive Director will review each change of condition incident to ensure compliance for three consecutive months.