22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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: 08/15/2024 10:35am to 1:00pm 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 07/31/2024 regarding allegations in the area(s) of: Personnel, resident care and related services, and buildings and grounds.
Number of residents present at the facility at the beginning of the inspection: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 7 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: 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: Buildings and grounds.
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 276-608-4514 or by email at rebecca.berry@dss.virginia.gov.
Based on a review of resident records and a medication cart audit, 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 #3 contained an order dated 01/04/2024 for Robafen DM Syrp, 2 teaspoons every four hours as needed. 2. The name of the medication was still listed on the August 2024 medication administration record (MAR) for resident #3, but was not available at the facility on the date of inspection.
Plan of Correction:
Residents cough syrup written 1/4/2024 had no refills, and when completed staff wrote rx completed on the MAR. In the future admin will oversee that a DC order is written even if no refills were wrote. [SIC]
Standard #:
22VAC40-73-880-B
Complaint related:
Yes
Description:
Based on observations made during a tour of the building, the facility failed to ensure that a space heater may be used only to provide or supplement heat in the event of a power failure or similar emergency. EVIDENCE: 1. A space heater was observed in the room for residents #1 and #2 in house #1. It was plugged in, but not operating at the time of inspection. There was not a power failure or similar emergency during the time of inspection. 2. Staff #1 reported resident #2 uses the space heater for short periods of time due to complications from a stroke, for circulation.
Plan of Correction:
Even though the resident has a doctor's order for heater, the heater will not be use and stored with residents personal belongings in closet. Administrator will purchase an electric throw blanket per suggestion of inspector. [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