VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sancerre Atlee Station
9495 Atlee Road
Mechanicsville, VA 23116
(804) 729-9200

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Jan. 17, 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

Comments:

Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/17/23 10:30 am to 2:20 pm The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: memory care, environment, medication storage and administration, staff/resident interactions Additional Comments/Discussion: Program documentation and resident and staff files were well-organized. An exit meeting will be 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident files, the facility did not ensure that all residents of and applicants to the assisted living facility shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110) and prior to admission. Evidence: The file documented that resident #4 was admitted to the facility on 9/12/23. The uniform assessment instrument for Resident # 4 was documented as completed on 9/14/23.
Plan of Correction:	Ensure that UAI assessments are completed before the admission process for every resident. Implement on 1/17/24 a timeline specifying that the UAI assessments be finalized before admission. It is mandatory for the team to use the UAI as the foundational document for the pre move?in assessment. Ongoing compliance will include quality assurance checks as part of the healthcare oversight to ensure compliance with the new process.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident files, the facility did not ensure that all residents of and applicants to the assisted living facility shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110) and prior to admission. Evidence: The file documented that resident #4 was admitted to the facility on 9/12/23. The uniform assessment instrument for Resident # 4 was documented as completed on 9/14/23.
Plan of Correction:	Ensure that UAI assessments are completed before the admission process for every resident. Implement on 1/17/24 a timeline specifying that the UAI assessments be finalized before admission. It is mandatory for the team to use the UAI as the foundational document for the pre move?in assessment. Ongoing compliance will include quality assurance checks as part of the healthcare oversight to ensure compliance with the new process.