VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chastain Home for Gentlewomen
370 Mountain Rd.
Halifax, VA 24558
(434) 476-6057

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

Inspection Date: Nov. 23, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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:

An on-site renewal inspections was conducted on 11/23/21 from 10am until 2pm in conjunction with a consultant from home office. A tour of the facility physical plant was conducted and the morning activity and mid day meal were observed. Resident and staff records as well as other forms of facility documentation were reviewed and interviews with resident were conducted. A meeting was held with the facility administrator at the end of the inspection to discuss violation cited and to give an opportunity to get feed back. Please respond back to your LI with your plan of correction. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to ensure that all required documentation was included in residents personnel and social information. EVIDENCE: 1. The personnel and social data sheet in the record for resident 1 did not contain documentation as to the residents current behavioral and social functioning including strengths and problems.
Plan of Correction:	On November 23, 2021, Resident 1, was interviewed by The Administrator as to her current behavioral and social functioning including strengths and Weaknesses. This Residents Personal Data Sheet is now completed, and in compliance.
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records, the facility failed to ensure that an orientation tot eh facility was conducted. EVIDENCE: 1. The record for resident 1 has a orientation to the facility form that has not been signed by the resident to acknowledge receiving the orientation.
Plan of Correction:	On November 23, 2021, Resident 1, was interviewed by The Administrator as to her Orientation to the facility form. Resident 1 has signed her Orientation Form, and this is completed, and now in compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident has documentation tha the resident has been prescribed a diabetic diet. The ISP dated 11/15/21 does not address this identified need.
Plan of Correction:	On November 23, 2021, Resident 1 had documentation as being prescribed a diabetic diet. The resident?s physician was contacted and has completed an addendum page to her physical, stating that the patient is to monitor her sugar intake. The resident takes no medication for diabetes. Resident 1 records is now in compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to store cleaning supplies in a locked area. EVIDENCE: 1. The door to the basement was unlocked on the day of inspection and several cleaning items and paint thinner was noted in the basement.
Plan of Correction:	On November 23, 2021, the door to the basement was unlocked and several cleaning items were noted. The administrator has spoken to each staff member, and the door to the basement is to be locked at all times. This has been corrected.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior on good repair. EVIDENCE: 1. Ceiling plaster/paint damage was noted to the left of the right front porch room. 2. Ceiling plaster/paint damage was noted in the right back corner of the dining room, the storm room and the activity room.
Plan of Correction:	On November 23, 2021, the facility failed to maintain the interior in good repair. The administrator met with the maintenance tech. and explained the importance of keeping the home in good repair. The ceiling /plaster has been repaired as of December 1, 2021. The ceiling /paint damage in the corner of the dining room has been repaired, and the storm room activity is now in process. This will be completed by December 20, 2021.