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: Sept. 18, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/18/2024 8:35am until 3:00pm 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The LI had a discussion with the facility Licensee in regard to standard 22VAC40-73-970, Fire and emergency evacuation drills, to ensure better understanding of the regulations. 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 #:	22VAC40-73-190-C
Description:	Based on staff record review and staff interviews, the facility failed to ensure that written documentation of duties and responsibilities were provided to the designated person in charge prior to them being placed in charge. EVIDENCE: 1. In interviews conducted on 09/18/2024 at 8:40am by the Licensing Inspector (LI) with staff persons 1 and 2, both staff persons 1 and 2 expressed that staff person 2 was the designated person in charge at the time of this interview. 2. A dry erase board hanging in the hallway by the computer room has documentation that staff person 2 is the designated person in charge for the second shift. 3. The record for staff person 2 did not contain documentation of written duties or responsibilities as the designated person in charge on the day of this inspection.
Plan of Correction:	Chart at the door will indicate who is in charge. RMA?s will be in charge of the shift when administrator is not here. Administrator will provide all registered medication aides with a written description of the duties and responsibilities for the shift and have them sign off on them.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that all required documentation included on a residents physical examination was completed by an independent physician. EVIDENCE: 1. The physical examination dated 08/18/2024 in the record for resident 3 has documentation that the residents ambulatory/non-ambulatory status was changed with documentation of ?she can walk to drugged at hospital to do anything? and signed by staff person 5, who is not an independent physician.
Plan of Correction:	The administrator reached out to her PCP and had him to fill out a new physical form to say she is ambulatory.
Standard #:	22VAC40-73-325-A
Description:	Based on resident record reviews, the facility failed to ensure that a fall risk rating was completed for residents who are assessed as assisted living level of care. EVIDENCE: 1. The public pay uniform assessment instrument (UAI) dated 09/15/2023 in the record for resident 2 has that resident 2 is assessed as a level 12, assisted living level of care. The record for resident 2 does not have documentation of a fall risk rating being completed for this resident.
Plan of Correction:	The administrator will complete a new fall risk plan for the resident.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations made of the facility medications carts, the facility failed to ensure that the storage area for medications was locked. EVIDENCE: 1. At 8:48am on 09/18/2024, the Licensing Inspector (LI) observed the facility medication cart sitting in the hall outside of the Laundry Room across from an area where residents were sitting. The cart was noted be unlocked and unattended. 2. At 8:57am the LI, in the presence of staff person 2, observed that the medication cart was sitting in the same place and was unlocked and unattended. Staff person 2 expressed that staff person 1, who was the registered medication aide (RMA) was down the hallway.
Plan of Correction:	The administrator met with all medication aides and reinforced state rules and regulations.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The door to the facility Laundry Room was noted to be open at 9:00am on 09/18/2024 and the room was unattended. An unlocked cabinet in the Laundry Room was noted to contain 3 bottles of C-L Bowl Cleaner and a bottle of HRX 75 Antibacterial Heavy Duty.
Plan of Correction:	The owner put a key lock pad on the door to ensure that the door is locked at all times.
Standard #:	22VAC40-73-860-J
Description:	Based on observations of the facility physical plant, the facility failed to ensure that residents who may be permitted to keep their own cleaning supplies or other hazardous materials stored them in an out-of-sight place so that they are not accessible to other residents. EVIDENCE: 1. The door to room 12 was noted to be open at 8:50am on 09/18/2024 and the room was unattended. A bottle of Luxury 100% Acetone Nail Polish Remover was observed sitting out on the top of a small refrigerator in the room.
Plan of Correction:	The administrator talked with the residents about putting away hazardous materials in her room.