VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fork Mountain Adult Rest Home
2925 Fork Mountain Road
Rocky mount, VA 24151

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE 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 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: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 10am until 12pm 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: 17 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-890-B
Description:	Based on observations of the facility physical plant, the facility failed to ensure that interior areas were adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. The lights in the ceiling of room 12 were noted to be inoperable on the day of inspection. The second light in the room was noted to have tape holding the light cover in place.
Plan of Correction:	The Licensee replaced the bulbs in one of the lights in room 12 on the day of inspection and will have the second light replaced/fixed.
Standard #:	22VAC40-73-920-D
Description:	Based on observations of the facility physical plant, the facility failed to ensure that grab bar s were located by all toilets. EVIDENCE: 1. The bathroom in room 12-A did not contain a grab bar by the toilet on the day of inspection.
Plan of Correction:	The Licensee will have a grab bar installed by the toilet in room 12-A.
Standard #:	22VAC40-73-960-B
Description:	Based on observations of the facility physical plant, the facility failed to ensure that the fire and emergency evacuation drawings contained all required information. EVIDENCE: 1. The fire and emergency evacuation drawing posted in the facility did not contain documentation of the areas of refuge or assembly areas.
Plan of Correction:	The Licensee will have the fire and emergency evacuation drawings updated to include area of refuge and assembly areas.