22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 SANCTIONS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 CRIMINAL PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 04/04/2023 9:00am until 12:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of participants present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 2
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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at Cynthia.ball@dss.virginia.gov
Based on participant record review and staff interview, the center failed to ensure that a participant assessment was reviewed and updated at least every six months.
EVIDENCE: 1. Participant 1 started attending the center on 06/21/2022. The most recent participant assessment in the record for participant 1 was dated 06/21/2022. Staff 1 confirmed this was accurate.
Plan of Correction:
Participant 1 assessment was updated on 04/04/2023.
Standard #:
22VAC40-61-230-D
Description:
Based on participant record review and staff interview, the center failed to ensure identified needs were included on participants plan of care (POC).
EVIDENCE: 1. The participant assessment for participant 4, dated 02/14/2023, indicated that the participant needs assistance with toileting from staff because the participant ?forgets to go if you are not with her/handrails?, needs assistance with dressing because the participant does not always put on the right amount of clothes, needs encouragement from staff because she doesn?t eat a lot, and is very confused and cannot follow simple direction. The POC for participant 4 does not include the aforementioned information and interview with staff 1 indicated that the information on the participant assessment is accurate and should be included in the participant?s plan of care.
Plan of Correction:
Participant 4 POC was updated and corrected to mirror exactly what the assessment stated on 04/04/2023.
Standard #:
22VAC40-61-410-F
Description:
Based on observations of the facility physical plant, the facility failed to ensure that all furnishings, fixtures, and equipment were in good repair.
EVIDENCE: 1. The sink located to the left in the men?s bathroom was inoperable on the day of inspection.
Plan of Correction:
A work order to fix the sink had been placed and parts ordered prior to inspection. Sink was back in working order on 04/05/2023.
Standard #:
22VAC40-61-460-H
Description:
Based on observations made of the facility physical plant, the facility failed to ensure that hot water temperatures at taps available to participants was maintained between 105?F and 120?F.
EVIDENCE: 1. The hot water coming from the sink to the right in the women?s bathroom was noted to be 133.9?F on the day of inspection.
Plan of Correction:
A work order was put in to adjust the water temp in the women?s bathroom on 04/04/2023. It was adjusted to 116? on 04/05/2023.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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http://www.dss.virginia.gov/facility/search/adc.cgi