VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 24, 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 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: 10/24/2023 8:40AM until 12:11PM 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: 13 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication administration, medication cart audit, noon-time meal 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on resident record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. The record for resident 2 contains resident care notes, dated 09/27/2023 at 6:00PM, that the resident fell as she was walking out of her bedroom into the hallway, hit her head, voiced pain in her head, had a knot appear in her upper left forehead that was red in color and the resident was sent to the emergency department by ambulance. The note also indicates that when facility staff reached out to the hospital for an update, the hospital informed the facility staff that the resident was being transferred to Collateral 2 for a minor brain bleed. A resident care note for the resident, dated 09/29/2023 at 7:00PM, states that the resident returned to the facility from the hospital on 09/29/2023 at 3:30PM 2. Hospital paperwork in the record for resident 2, dated 09/28/2023, indicates that the resident had a fall at the facility and had a subarachnoid. 3. Interview with staff person 4 revealed that an incident report was not sent to the regional licensing office regarding the aforementioned incident.
Plan of Correction:	Going forward regional licensing office will be notified within 24 hours of all falls that result in hospitalization.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure fall risk rating shall be reviewed and updated after a fall. EVIDENCE: 1. The record for resident 2 contains a resident care note, dated 09/27/2023 at 6:00PM, that the resident fell as she was walking out of her bedroom into the hallway. 2. The most recent fall risk rating the record for resident 2 is dated 07/10/2023 for a fall that the resident had on 07/04/2023. Interview with staff person 4 confirmed that this is accurate.
Plan of Correction:	Fall risk for resident 2 was updated to reflect fall on 09/27/2023. Administrator will use tickler files to ensure resident information is kept up to date.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the physical plant, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. On 10/24/2023 at 9:00am, the floor in kitchen, near the ice machine, it was noted that the tile was worn and missing pieces. 2. On 10/24/2023 at 9:00am, the floor in the kitchen, around the freezer, it was noted to have a dark stain that appears to be dirty and have a substance adhered to the floor. 3. On 10/24/2023 at 9:00am, the floor in the kitchen, around the silver refrigerator, it was noted to have tiles that were worn and missing pieces. It was also noted that the area was noted to have a dark stain that appears to be dirty and have a substance adhered to the floor. 4. On 10/24/2023 at 9:00am, the floor in the kitchen, near a silver shelf, it was noted that the tile was worn and missing. 5. On 10/24/2023 at 9:00am, the floor in the kitchen, in front of the sink, it was noted that the tile was worn and missing pieces. 6. On 10/24/2023 at 9:01am, the floor in the kitchen, to the right of the dishwasher, it was noted to have a dark stain that appears to be dirty and have a substance adhered to the floor.
Plan of Correction:	Entire kitchen floor will be replaced.