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: Nov. 19, 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/19/2024 8:30am until 2:00pm 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: 17 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: 2 Number of interviews conducted with residents: 2 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 #:	22VAC40-73-1030-B
Description:	Based on staff record review, the facility failed to ensure that within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment. EVIDENCE: 1. The records for staff persons 1 and 2, both hired on 06/18/2024, have documentation that the employees have completed only 4 of the required 6 hours of training for individuals with cognitive impairments as of the day of on-site inspection.
Plan of Correction:	Staff completed 6 hours of cognitive training on 11/26/2024.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI dated 04/18/2024 in the record for resident 2 has documentation that the resident is disoriented to some spheres some of the time but does not have documentation to identify what spheres are affected.
Plan of Correction:	Residents UAI was updated to show which spheres were affected.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans were reviewed and updated as needed when a change in a residents condition occurred. EVIDENCE: 1. The record for resident 1 has a fall risk completed on 11/05/2024 with a score of 30 to indicate that the resident is a risk for falls. The ISP dated 11/05/2024 in the record for resident 1 does not have documentation of resident 1?s risk for falls or of any interventions in place for fall prevention. 2. The record for resident 2 has a fall risk completed on 04/26//2024 with a score of 15 to indicate that the resident is a risk for falls. The ISP dated 04/27/2024 in the record for resident 2 does not have documentation of resident 2?s risk for falls or of any interventions in place for fall prevention.
Plan of Correction:	Resident 1 ISP was updated to show she is a high fall risk. Resident 2 is a low fall risk. According to the assessment she has more than 1 diagnosis so she is automatically a 15. Resident has not had any falls. ISP was updated to show low fall risk.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. At 8:46am on the day of on-site inspection the LI observed the facility laundry room door to be open. The unlocked cabinets in the laundry room contained Water Flakes Bowl Cleaner, C-L Bowl Cleaner, LA?s Total Awesome Cleaner with Bleach, Window Cleaner, Great Value Disinfectant Spray and a bottle of A2Z Disinfecting Glass & Multi Surface Cleaner was sitting out on the shelf. The LI noted that staff person 1 was standing in the hallway at the medication cart outside of the laundry room but no staff were present in the laundry room at the time of observations.
Plan of Correction:	Staff was standing outside of door but Staff will ensure that the door is closed at all times. Staff will immediately close the door after taking resident to the bathroom. Staff will stop what they are doing to close door.