VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Countryside Assisted Living, LLC
1240 Orange Road
Pratts, VA 22731
(540) 948-6318

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: May 22, 2024

Complaint Related: No

Areas Reviewed:

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 63.2- (18) FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Discussed including the person in charge on the work schedule to simplify the requirements in 22VAC40-73-290

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: May 22, 2024 7:45am-3:45pm; May 23, 2024 7:45am-4:00pm 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents participating in activity program, eating lunch, and medication pass to residents. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on record review and staff interview, the facility failed to ensure that, within four months of starting date of employment, direct care staff attended six hours of training in working with individuals who have a cognitive impairment. EVIDENCE: 1. The facility serves a mixed population. 2. The record for Staff 2 (date of hire: 4/20/23) did not contain documentation of six hours of training working with individuals with cognitive impairment. 3. Staff 5 confirmed that six hours of cognitive impairment training was not completed.
Plan of Correction:	Practice put into place to maintain and monitor required education for each staff member. Two hours of training completed with the final four hours scheduled.
Standard #:	22VAC40-73-1030-D
Description:	Based on record review and staff interview, the facility failed to ensure that, within one month of start date of employment, staff other than the Staff 5 and direct care staff completed two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care. EVIDENCE: 1. The facility serves a mixed population. 2. The record for Staff 3 (date of hire: 4/22/24) did not contain documentation of two hours of training working with individuals with cognitive impairment. 3. Staff 5 confirmed that two hours of cognitive impairment training was not completed.
Plan of Correction:	Practice put into place to maintain and monitor required training for each staff member hired to have a minimum of two hours within the first thirty days of employment.
Standard #:	22VAC40-73-100-A
Description:	Based on record review and staff interview, the Staff 5 failed to ensure that at least an annual review of infection prevention policies and procedures for any necessary updates were completed and that documentation was maintained at the facility. EVIDENCE: 1. The facility did not have documentation that an annual review was completed. 2. Staff 5 stated a review of the Infection Control Program was not performed.
Plan of Correction:	Practice put into place to monitor and maintain required staff education for each staff member. Review of Infection control program was completed with all staff,
Standard #:	22VAC40-73-200-D
Description:	Based on record review and staff interview, a direct care aide (DCA) did not obtain a copy of issued certificate or other documentation indicating requirements were met. EVIDENCE: 1. The record for Staff 2 (date of hire 4/20/2023) did not contain a copy of documentation indicating qualification to be a DCA. 2. Staff 5 acknowledged the qualifications for DCA training were not on file for Staff 2.
Plan of Correction:	Staff file has been updated to reflect all certifications and training. Practice in place to maintain and monitor certifications/documents of qualifications.
Standard #:	22VAC40-73-270-1
Description:	Based on record review and staff interview, the facility failed to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior prior to being involved in the care of such residents. EVIDENCE: 1. The record for Staff 1 (date of hire 4/20/2023) does not contain documentation that they had training in methods of dealing with residents who have a history of aggressive behavior prior to being involved in the care of such residents. 2. Staff 5 stated that aggressive training was not completed for Staff 1 and confirmed that the facility does accept and currently has 2 residents who are or who may be aggressive.
Plan of Correction:	Practice put into place to monitor and maintain required training for each staff member. All current staff trained/retrained 6/20/24. All new staff will be trained prior to working or being involved with residents with aggressive behavior
Standard #:	22VAC40-73-290-A
Description:	Based on record review and staff interview, the facility failed to ensure the staff schedule included the job classification of all staff working each shift and indicated whoever was in charge at any given time. EVIDENCE: 1. A copy of the staff schedule for 5/11/2024 through 5/25/2024 did not include job classification and who was in charge at any given time. 2. Staff 5 acknowledged that the job classification was not included on the schedule.
Plan of Correction:	Staff schedule has been corrected to reflect staff job classification and the ?charge? person on duty for each shift
Standard #:	22VAC40-73-310-M
Description:	Based on record review, the facility failed to ensure the written agreement between the assisted living facility and hospice program included all requirements. EVIDENCE: 1. One of two hospice agreements reviewed (dated March 2024) did not include listing of services provided, acknowledgment of services provided to each resident, and signatures of authorized representatives.
Plan of Correction:	Hospice agreement has been updated to include services provided, acknowledgement of services provided to each resident and required signatures of authorized representatives.
Standard #:	22VAC40-73-490-D
Description:	Based on record review and staff interview, the facility failed to ensure that specific residents for whom the health care oversight (HCO) was provided were identified. EVIDENCE: 1. The HCO, completed 3/11/2024, did not include a list of residents that were reviewed. 2. Staff 5 confirmed there was no list of residents who were reviewed during the HCO.
Plan of Correction:	(HCO) policy has been corrected to include a list of residents reviewed,
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interview, the facility failed to ensure the posted menu included snacks. EVIDENCE: 1. During facility tour, the posted menu was observed and did not include snacks. 2. Staff 5 acknowledged that the posted menu did not include snacks.
Plan of Correction:	A list of available snacks for all residents has been posted with the current menus
Standard #:	22VAC40-73-890-D
Description:	Based on observation and staff interviews, the facility failed to ensure that flickering fluorescent lights were replaced. EVIDENCE: 1. During tour of building licensing staff observed a flickering fluorescent ceiling light between a resident room and a common area. 2. Staff 5 acknowledged the light flickered and needed to be replaced. 2. Photo evidence taken.
Plan of Correction:	Flickering lights have been replaced with new LED lighting. Continuous visual inspection of all lights will be done and corrective action taken immediately.
Standard #:	22VAC40-73-930-A
Description:	Based on observation and staff interview, the facility failed to provide a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff the resident needs assistance. EVIDENCE: 1. During facility tour, licensing staff did not observe signaling devices in all resident rooms. Resident rooms were not numbered for identification. 2. When asked if all resident rooms have a signaling device, Staff 5 acknowledged that a signaling device was not available to all residents in bedrooms.
Plan of Correction:	All occupied resident' rooms have been numbered for identification. All occupied resident rooms have signaling devices.
Standard #:	22VAC40-73-930-D
Description:	Based on staff interview, the facility failed to ensure documentation was completed and maintained of staff rounds that included the name of the resident, date and time of rounds, and the staff member who made the rounds. EVIDENCE: 1. A rounding log was requested for review. 2. Staff 5 acknowledged that the rounding log did not exist.
Plan of Correction:	Hourly round log was created and put into practice for each resident to include resident name, date, time and staff name.
Standard #:	22VAC40-73-960-C
Description:	Based on observations and staff interviews, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center were posted by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. On 5/22/2024, during a tour of the facility, licensing staff observed the emergency numbers were not posted by the telephone shown on the facility emergency evacuation plan. 2. Staff 5 acknowledged that emergency numbers were not posted. 3. Photo evidence was taken.
Plan of Correction:	Based on inspection the resident telephone has been moved and replaced with a new red phone for better accessibility and sight. ALL required numbers have been posted directly above the phone in large font for clarity
Standard #:	22VAC40-73-970-E
Description:	Based on record review and staff interview, the facility failed to document all required information for fire drills. EVIDENCE: 1. Fire drill logs (dated 9/26/2022 through 4/26/2024) did not include, person conducting the drill, notification method, time to complete the drill, and any encountered problems. 2. Staff 5 acknowledged that the above information was not included in the fire drill log.
Plan of Correction:	Based on inspection the fire drill documentation procedure has been updated and changed to reflect the correct layout with all required information
Standard #:	22VAC40-73-990-A
Description:	Based on staff interview, the facility failed to ensure a written plan for resident emergencies was completed and on file. EVIDENCE: 1. A written plan for resident emergencies was requested for review. 2. Staff 5 acknowledged the plan did not exist.
Plan of Correction:	A written policy and procedure has been created and implemented for resident emergencies, placed on file and reviewed by all staff
Standard #:	22VAC40-90-40-B
Description:	Based on the staff record review, the facility failed to ensure the criminal history record report (CHRR) was obtained on or prior to the 30th day of employment for each staff. EVIDENCE: 1. Staff 6 (date of hire 11/28/2023) contains a CHRR received date of 5/14/24. 2. Staff 7 (date of hire 8/10/2023) contains a CHRR received date of 5/14/24. 3. Staff 5 acknowledged the dates on the CHRRs and the dates of hire exceeded 30 days from the date of hire.
Plan of Correction:	Email communication with VA State Police to direct us in applying for online registration/access to obtain employee criminal history within the required time. Practice in place for any new employee the request for a criminal history report will be mailed to VSP on date of hire until the above process has a final resolution.