VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Showalter Center
1060 Showalter Drive
Blacksburg, VA 24060
(540) 443-3427

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Dec. 6, 2023 and Dec. 7, 2023

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

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: 12/06/2023, 10:10am to 2:58pm and 12/07/2023, 10:05am to 3:40pm 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: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: 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 #:	22VAC40-73-870-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. Several small dark spots/stains were observed on the carpet in resident room #409, in the living area near the TV tray table. 2. In resident room #313, there were several specks of dirt or crumbs observed on the carpet in the living area, particles of cat litter on the floor next to the litter box and several pieces of cat food on the kitchen floor, in the area where the cat food bowls are located.
Plan of Correction:	1. Housekeeping deep cleaned carpet on 12/13/23 and spots were removed. 2. Housekeeping cleaned apartment on 12/8/23 and is cleaned every Friday. Housekeeping manages cat litter changing every Friday. Carpet was deep cleaned on 12/14/23 and kitchen floor was mopped. Ongoing: Director of Housekeeping/designee will continue to deep clean carpet in apartments once per year and as needed (apartments are on a rotating schedule throughout year). Director of Housekeeping/designee to monitor cleanliness of floors. [SIC]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. The licensing inspector (LI) observed a strong foul odor upon walking into resident room #313. 2. The LI observed a strong foul odor upon walking into resident room #402. 3. The LI observed an odor resembling urine in resident room #216, in the hall/closet area between the bedroom and the bathroom.
Plan of Correction:	1. Housekeeping staff deep cleaned floor and carpet on 12/14/23 as stated above. Housekeeping will continue to change cat litter box on Fridays but Director of Housekeeping/designee will check room for cleanliness and smells and address as needed. 2. Resident of 402 manages her cat litter box herself; however, housekeeping staff will remove trash (and discarded cat litter) as needed. 3. Environmental services staff manages resident?s laundry every Thursday. Housekeeping staff to use odor control products in closet to reduce odor from soiled laundry. Ongoing: Director of Housekeeping/designee to monitor odors in apartments and common areas and address as needed. [SIC]