VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fort Shelby Manor
200 Solar Street
Bristol, VA 24201
(276) 669-3562

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: May 23, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 05/23/2024, 10:35am to 4:03pm 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Noon meal, activity, med pass Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-210-D
Description:	Based on a review of staff records, the facility failed to ensure that for medication aides, completion of continuing education required by the Virginia Board of Nursing for one of the staff records reviewed. EVIDENCE: 1. The hire date for staff #3 was 05/01/2020. The initial Registered Medication Aide (RMA) registration occurred on 09/22/2022, and current registration expires 09/30/2024. There was no documentation of completion of an annual four-hour refresher course for RMAs observed in the record for staff #3.
Plan of Correction:	A 4 hour refresher course has been completed for all medication aides on June 6, 2024. Administrator will make sure that all medication aides will have the required refresher course annually.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for one of the staff records reviewed. EVIDENCE: 1. The date of hire for staff #1 was 12/04/2022. The most recent Report of Tuberculosis Screening observed in the record for staff #1 was completed on 11/04/2022.
Plan of Correction:	The form was done by the physician, however it had not been filed. The physician assessed all staff and residents. The date of the assessment for Staff #1 is May 30, 2024. The Administrator will see that all annual assessments are done and filed promptly.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment for one of the staff records reviewed. EVIDENCE: 1. The date of hire for staff #2 was 02/08/2024. There was no current first aid certification observed in the record for staff #2. The previous certification was issued 10/24/2019 and recommended renewal date was 10/2021.
Plan of Correction:	Administrator is in the process of scheduling and CPR/FIRST AID class in the next 30 days. All direct care staff, other than one have CPR/FIRST AID. Administrator will make sure that all direct care staff are current on CPR/FIRST AID training.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for one of the resident records reviewed. EVIDENCE: 1. Resident #3 was admitted to the facility on 11/13/2020. The most recent ISP observed in the record for resident #3 was completed 11/10/2022.
Plan of Correction:	Administrator will make sure that every residents individualized service plan (ISP) is reviewed and updated at least annually. Resident #3s ISP has been reviewed and updated June 1, 2024. [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident and staff records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person, and to maintain written acknowledgment of having been so informed, which shall include the date of the review, in the resident's or staff person's record. EVIDENCE: 1. The date of hire for staff #1 was 12/04/2022. The most recent Staff Review of Resident Rights observed in the record for staff #1 occurred on 12/04/2022. 2. Resident #2 was admitted to the facility on 08/14/2014. The most recent Annual Review of Resident?s Bill of Rights observed in the record for resident #2 occurred on 03/13/2023. 3. Resident #3 was admitted to the facility on 11/13/2020. The most recent Annual Review of Resident?s Bill of Rights observed in the record for resident #3 occurred on 03/13/2023.
Plan of Correction:	Administrator will make sure that each resident or his representative will have written knowledge annually of his or her resident rights, and it will be documented in their file. Also each staff person will be made aware of the resident rights, and it will be documented in their individual files. Administrator has gone over the resident rights with Resident #2 and #3, also with staff #1, and it is documented in their file. [SIC]
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. EVIDENCE: 1. In the women?s house, the menu posted was for the week ending 05/04/2024, three weeks prior to the date of inspection.
Plan of Correction:	Administrator will see that current menus for meals and snacks are posted in a conspicuous place on a regular basis. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure bedrooms shall contain all required items: EVIDENCE: 1. In the women?s house, resident room #2 did not contain an operable bed lamp or bedside light for resident #6. 2. In the women?s house, resident room #10 did not contain an operable bed lamp or bedside light for resident #7. 3. In the men?s house, resident room #2 contained only one operable bed lamp or bedside light but is assigned three residents. 4. In the men?s house, resident room #3 contained two lamps that were missing light bulbs. 5. In the men?s house, resident room #4 did not contain an operable bed lamp or bedside light for resident #8. 6. In the men?s house, resident room #5 was assigned four residents but contained only three operable bed lamps or bedside lights.
Plan of Correction:	1. Resident #6 in women's has access to an operable lamp. 2. Resident #7 in women's has access to an operable lamp. 3. In men's house, resident room #2, now has 3 lamps. 4. In men's house, resident room #3, 2 lamps have bulbs. 5. In men's house, resident #8 now has an operable lamp. 6. In men's house, room #5 now has 4 operable lamps. Administrator will make sure that each resident has access to an operable lamp. [SIC]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during a tour of the building, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. EVIDENCE: 1. In the women?s house, the water in the sink in restroom B1 reached a temperature of 151 degrees Fahrenheit. 2. In the men?s house, the water in the sink in the restroom by the dining area reached a temperature of 137 degrees Fahrenheit.
Plan of Correction:	The temperature in both bathrooms has been adjusted to be within the range of 105'F to 120'F. Administrator will make sure that water stays within the range of 105'F to 120'F. Administrator will have the temperature checked weekly. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In the women?s house in resident room #2, there were several used Styrofoam cups on the beside table and on the floor by the bed for resident #6. There was also crumpled tissues/napkins and empty food wrappers observed by the same bed. 2. In the women?s house in resident room #3, there were large holes observed in the ceiling. Per staff, a leak in the bathroom above the room cause the damage. There are no residents currently using the room. 3. In the women?s house on the third floor, the doors on the closet by the elevator were off the track.
Plan of Correction:	1. Resident room #2 is now free of any trash and rubbish. Staff is to check daily to make sure that all rooms are kept free of trash and rubbish. 2. In women's house, resident room #3, the ceiling has been repaired and the room now has two residents in it, 3. In the women's house third floor, the doors to the closet are back on the track. Administrator will check both houses daily for trash and rubbish and any repairs that need attention. [SIC]
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during a tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. In the women?s house, the fourth-floor restroom by the stairs had a sink and toilet that were out of order at the time of inspection. 2. In the men?s house in resident room #2, resident #9 indicated there was a small hole in his mattress approximately two to three inches in diameter going all the way through the depth of the mattress. The licensing inspector (LI) did observe the hole in the mattress. 3. In the men?s house in resident room #3, the LI observed a large indentation in the mattress for resident #2, in the center on the side of the bed opposite the wall.
Plan of Correction:	1. In the women's house, the 4th floor rest room sink and toilet are in working order. 2. In regards to the mattress observed by inspector, administrator has decided that the mattresses do not need to be replaced at this time. Administrator will monitor mattresses weekly and if needed, mattresses will be replaced. Administrator will check on a daily basis with staff any needed repairs, and will see that repairs are done in a timely manner. [SIC]