22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 7-19-24 from 10:42 a.m.- 12:05 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 5-16-24 regarding allegations in the area(s) of: the secure environment.
Number of residents present at the facility at the beginning of the inspection: 48 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: A tour of the identified area of the facility was also completed.
An exit meeting was conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a self-report received from the facility on 5-16-24, the facility failed to ensure monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms.
Evidence: Based on an interview with Staff # 1, as well as a review of the record for Resident # 1, the resident was able to exit the main front door entrance of the memory care unit on 5-15-24 and walk to the end of the ramp before staff could reach the resident and escort her back into the facility. The resident?s roam bracelet was determined to not be functioning properly.
Plan of Correction:
All Memory Support entrances/exits were assessed for functioning and alarms. Assessment completed on 5/16/24 by ALUM, LNHA, MM, and MS. The door alarm sound increased. 5/20/24 Wander guard was replaced on 5/16/24 Staff to check for wander guard functioning once daily. 5/16/24
Standard #:
22VAC40-73-460-D
Description:
Based on a self-report received from the facility on 5-16-24, the facility failed to ensure that it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of wandering from the premises.
Evidence: Based on a review of facility documentation and an interview with Staff # 1, Resident # 1 was able to wander from the memory care unit and exit the facility on 5-15-24, reaching the end of the ramp before staff reached her.
Plan of Correction:
One staff member is to remain in common areas on the unit to monitor residents. Staff to initiate a person-centered activity when the resident is exit-seeking, initiate an outside activity in the courtyard, or take a walk with the resident outside.
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.
Find this content at:
http://www.dss.virginia.gov/facility/search/alf.cgi