22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND
Comments:
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/09/2024, 10:55am to 11:30am, 08/08/2024 3:01pm to 3:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/01/2024 regarding allegations in the area(s) of: Resident care and related services, personnel, resident accommodations and related provisions, staffing, building and grounds.
Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility policies Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident accommodations and related provisions.
A violation notice was issued; any violation(s) not related to the complaint(s) 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on interview with staff and review of facility documentation, the facility failed to develop and implement a written policy regarding pets living on the premises that will ensure the safety and well-being of all residents and staff. EVIDENCE: 1. The only available policy regarding pets living in the assisting living facility was developed by the previous licensee. Per the policy, there could only be one pet on the premises at any given time, and the one pet allowed belonged to the owner of the facility. 2. Per interview with staff #1, a new policy had not been developed or implemented by the current licensee.
Plan of Correction:
New Policy has been written that there are to be no pets allowed at the facility by any residents. [SIC]
Standard #:
22VAC40-73-840-B
Complaint related:
Yes
Description:
Based on observations made during a tour of the building and interview with staff, the facility failed to ensure that if a facility allows pets to live on the premises, before being allowed to live on the premises, pets shall have had all recommended or required immunizations and shall be certified by a licensed veterinarian to be free of diseases transmittable to humans. EVIDENCE: 1. Upon entering the room for resident #1, the licensing inspector (LI) observed an orange cat. 2. There were bowls of cat food and water in the floor of the room, and a litter box was observed in the bathroom, between the toilet and the sink. 3. Per staff #1, the cat was a stray and there was no documentation of any required immunizations, and the cat was not certified by a licensed veterinarian to be free of diseases transmittable to humans.
Plan of Correction:
Pets will no longer be allowed at the facility expect to visit. Pets visiting will have all vet records on file. [SIC]
Standard #:
22VAC40-73-870-A
Complaint related:
No
Description:
Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In the room for resident #1, there was a can of potato chips observed on the floor next to the bed, with several crumbs on the floor around the can. There was a what appeared to be a crumpled food wrapper under the bed as well as other dust and debris under the bed. 2. In the same room, there were several items of what appeared to be dirty laundry in a pile on the floor in front of the furniture located by the door leading to the outside.
Plan of Correction:
Resident Rules is that food is not allowed in resident rooms. Rooms are to be cleaned daily by direct care and/or housekeeping staff. [SIC]
Standard #:
22VAC40-73-870-B
Complaint related:
Yes
Description:
Based on observations made during a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. Upon entering the room for resident #1, the licensing inspector observed a strong, foul odor. 2. There was a cat litter box observed in the adjoining bathroom that appeared to need cleaning, likely contributing to the foul odor.
Plan of Correction:
The cat and litter box has been removed and animals are no longer allowed at the facility. [SIC]
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/alf.cgi