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: Nov. 1, 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 GROUNDS 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/01/2024 7:15AM to 12:30PM 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: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication administration, medication cart audit, breakfast and noon-time meals Additional Comments/Discussion: To ensure the facility has a thorough understanding of the standards, the licensing inspector (LI) and the licensing administrator (LA) had a discussion with the administrator and the director of maintenance regarding standard 22VAC40-73-880-C.1. & 2. To ensure the facility had a thorough understanding of the standards, the LI had a discussion with the director of maintenance regarding standard 22VAC40-73-860-G. 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 #:	22VAC40-73-210-F
Description:	Based on staff record review and staff interview, the facility failed to ensure when adults with mental impairments reside in the facility, at least four hours of the required 18 hours of annual training for direct care staff shall focus on topics related to residents? mental impairments. EVIDENCE: 1. Interview with staff person 3 revealed there are residents that reside in the facility that have mental impairments. 2. The record for staff person 1, date of hire 11/18/2022, only contains documentation that the staff person had one hour of training that focused on residents? mental impairments during the training year 11/18/2022 to 11/17/2023. Staff person 3 confirmed this is accurate.
Plan of Correction:	Staff 1 will have all required training complete. Administrator will ensure 3 additional hours of training focusing on mental impairment will be added to annual training.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review and staff interview, the facility failed to ensure verification that the staff person has received a copy of his current job description was maintained on staff and included in the staff record. EVIDENCE: 1. Interview with staff person 3 revealed that staff person 2 has been a registered medication aide (RMA) since 10/16/2024 and has administered medications to residents at the facility. 2. The record for staff person 2 does not contain documentation of the staff person?s job description or verification that the staff person received a copy of their current job description since becoming an RMA. Interview with staff person 3 confirmed this is accurate.
Plan of Correction:	Current job description signed by staff 2 and placed in employee file. Administrator will ensure going forward when staff take on a new position a new job description will be complete.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually, when the condition of the resident changes and after a fall. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 3, dated 05/02/2024, indicates the resident is assisted living level of care. 2. Facility staff notes indicate that the resident had a fall on 10/06/2024 and 10/30/2024. Interview with staff person 3 revealed that the fall risk rating for the resident has not been reviewed and updated for either fall.
Plan of Correction:	Fall risk on resident 3 completed. Administrator will use ticker files to ensure resident information is kept up to date.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. EVIDENCE: The most recent UAI in the record for resident 2 is dated 10/10/2023. Interview with staff person 3 confirmed this is accurate.
Plan of Correction:	UAI for resident 2 was completed. Administrator will use tickler files to ensure resident information is kept up to date.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months. EVIDENCE: The most recent ISP in the record for resident 2 is dated 10/10/2023. Interview with staff person 3 confirmed this is accurate.
Plan of Correction:	ISP for resident 2 was completed. Administrator will use tickler files to ensure resident information is kept up to date.
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person and the staff person?s written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person?s record. EVIDENCE: Interview with staff person 3 revealed that staff person 1 reviewed the rights and responsibilities of residents in July 2024; however, the staff person did not sign and date that she attended the review and was not filed in the staff person?s record.
Plan of Correction:	Resident Rights will be reviewed and signed by all staff. This will be done annually.
Standard #:	22VAC40-73-670-1
Description:	Based on resident record review and staff record review, the facility failed to ensure when staff administers medications to residents, each staff person who administers medication shall be authorized by 54.1-3408 of the Virginia Drug Control Act and all staff responsible for medication administration shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. EVIDENCE: 1. The Virginia Department of Health Professions License Lookup website indicates staff person 2?s registered medication aide (RMA) initial license date is 10/16/2024; however, October 2024 medication administration records (MARs) contain documentation that staff person 2 administered medications on 10/11/2024. 2. October 2024 MARs indicate that staff person 2 administered scheduled medications to the following residents on 10/11/2024: resident 1 at 8:00AM and 2:00PM; resident 2 at 8:00AM, 12:00PM and 4:00PM; resident 3 at 7:30AM, 8:00AM, 12:00PM, 2:00PM, 4:00PM, 4:30PM and 5:00PM; resident 4 at 8:00AM and 5:00PM; resident 5 at 8:00AM and 2:00PM; resident 6 at 8:00AM; resident 7 at 8:00AM, 12:00PM, 4:00PM, 6:00PM and an as needed (PRN) medication at 4:50PM; resident 8 at 8:00AM and 2:00PM; resident 9 at 8:00AM and 2:00PM; resident 10 at 7:30AM, 8:00AM and an as needed (PRN) medication at 6:53PM; and resident 11 at 8:00AM.
Plan of Correction:	Administrator will ensure going forward that no RMA will pass medication until license date is reflected on the Virginia Board of Nursing website.
Standard #:	22VAC40-73-680-M
Description:	Based on resident record review and staff interview, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 10/11/2024, for acetaminophen 325MG tablet, take two tablets by mouth every four hours as needed for fever, pain, or headache. 2. Interview with staff person 3 revealed that this PRN medication was not available at the facility for resident 1.
Plan of Correction:	Prn Tylenol for resident 1 is available in med cart. Going forward staff will utilize new order binder to ensure all orders arrive promptly.
Standard #:	22VAC40-73-690-G
Description:	Based on resident record review and staff interview, the facility failed to ensure action taken in response to the recommendations of the medication review shall be documented in the resident?s record. EVIDENCE: 1. The facility?s most recent medication review conducted on 06/06/2024, contains a recommendation for residents 1, 2 and 3. 2. Interview with staff person 3 revealed that the recommendations for residents 1, 2 and 3 had been sent to the residents? physician; however, staff person 3 has not received a response back from the physicians regarding the recommendations for residents 1, 2 and 3.
Plan of Correction:	Folder placed in med room with copy of pharmacy recommendations for provider review. When provider visits the facility he will sign off on recommendations and sent back to pharmacy.
Standard #:	22VAC40-73-950-C
Description:	Based on staff interview, the facility failed to ensure by December 1, 2020 an assisted living facility that is not equipped with an outside emergency generator shall enter into an agreement with a vendor capable of providing the facility with an emergency generator for the provision of electricity during an interruption of the normal electric power supply and enter into at least one agreement with a separate vendor capable of providing an emergency generator in the event that the primary vendor is unable to comply with its agreement with the facility during an emergency. EVIDENCE: 1. Interviews with staff persons 3 and 4 verified that the facility does not have an onsite emergency generator. 2. During on-site inspection, staff person 3 was unable to provide to the licensing inspector (LI) evidence of an agreement with a vendor capable of providing the facility with an emergency generator for the provision of electricity during an interruption of the normal electric power supply. Staff person 3 was also unable to provide to the LI evidence of at least one agreement with a separate vendor capable of providing an emergency generator if the primary vendor is unable to comply with its agreement with the facility during an emergency.
Plan of Correction:	Waiting to hear back on a plan for generator
Standard #:	22VAC40-73-950-E
Description:	Based on facility documentation review and staff interview, the facility failed to ensure the semi-annual review on the facility?s emergency preparedness and response plan for residents shall be documented by signing and dating. EVIDENCE: Residents reviewed the facility?s emergency preparedness and response plan on 09/14/2024; however, interview with staff person 3 revealed that residents did not sign and date that they had completed the review.
Plan of Correction:	Emergency preparedness and response plan with residents complete with date and signatures.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation during a walkthrough of the facility, the facility failed to ensure the findings of the most recent inspection of the facility was posted on the premises. EVIDENCE: The most recent inspection completed at the facility was on 08/05/2024; however, during the walkthrough of the facility, it was noted by the licensing inspector that the inspection posted was from 10/24/2023.
Plan of Correction:	Copy of inspection dated 8/5/24 is posted.