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 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

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. A self-reported incident was received by VDSS Division of Licensing on 07/30/2024 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 16 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-470-A
Description:	Based on resident record review, the facility failed to ensure that the health care service needs of a resident were met. EVIDENCE: 1. A facility incident report dated 07/28/2024 has documentation that resident 1 has a fall on 07/28/2024 and was sent to the local emergency room. 2. The record for resident 1 has a Hospital summary dated 07/29/2024 with documentation on page 2 under Medical Decision Making that states ?Left shoulder films obtained to eval for shoulder fracture which resulted in no evidence of fracture though does show findings suggestive of possible rotator cuff injury. Will place in sling and referral to orthopedic surgery to evaluate this as outpatient?. 3. The record for resident 1 does not have any documentation that the resident has been seen by an orthopedic surgeon for an evaluation for a rotator cuff injury.
Plan of Correction:	The administrator met with doctor and had her put in writing and sign off on it, that resident does not need to be seen or referred to a orthopedic doctor.